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TREATISE   ON  THE 

DISEASES   OF   WOMEN 


FOR    THE    USE   OF  STUDENTS 
AND   PRACTITIONERS 


BY 

ALEXANDER  J.  C.  SKENE,  M.  D.,  LL.D. 

Professor  of  Gynecology  in  the  Long  Island  College  Hospital,   Brooklyn,  N.  Y. 

formerly   Professor  of  Gynecology  in  the   New  York    Post-Graduate   Medical 

School ;  Gynecologist  to  the  Long  Island  College  Hospital ;  President  of 

the  American  Gynecological  Society,  1887 ;  Corresponding  Member  of 

the  British,    Boston,   and  Detroit  Gynecological  Societies,   of  the 

Royal  Society  of  Medical  and  Natural  Sciences  of  Brussels,  of 

the  Obstetrical  and  Gynecological  Society  of  Paris,  and  of 

the  Leipzig  Obstetrical  Society  ;  Honorary  Member  of 

the  Edinburgh  Obstetrical  Society  ;  Fellow  of  the 

New  York  Academy  of  Medicine  ;  ex-President 

of  the  Medical  Society  of  the  County  of 

Kings  ;  ex-President  of  the  New  York 

Obstetrical  Society 


THIRD    EDITION,    REVISED   AND    ENLARGED 
WITH    290    ENGRAVINGS   AND   4    PLATES    IN    COLORS 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1900 


^G  /  u 


t^J 


Copyright,  1888,  1892,  1897, 
D.   APPLETON  AND  COMPANY. 


^ 


en 


Oi 


i 


TO 

THOMAS   KEITH,   M.  D.,  LL.  D.,  F.  R.  C.  S.  E., 

^f^  THIS   WORK   IS    DEDICATED 

Gi  AS    A    TRIBUTE    TO    HIS    ACHIEVEMENTS    IN    SURGERY, 

«-" 

..  HIS   JUSTICE    AND   COURTESY   TO   THE    MEDICAL    PROFESSION   OF    AMERICA, 


AND   AS   AN   ACKNOWLEDGMENT   OF   HIS    KINDNESS    TO    THE    AUTHOR. 


2: 


PREFACE  TO  THE  THIRD  EDITIOK 


In  no  department  of  medicine  have  more  rapid  and  greater 
strides  been  made  during  the  present  decade  than  in  gynecology. 
During  this  period  many  things  new  and  useful  have  been  added 
to  the  science  and  the  art,  while  much  that  is  both  old  and  new 
deserves  to  be  forgotten.  To  preserve  and  present  to  the  student 
and  practitioner  that  which  his  own  experience  and  that  of  the 
highest  authorities  in  this  country  and  abroad  have  demonstrated 
to  be  worthy  of  their  confidence,  has  been  the  author's  aim  in  the 
preparation  of  this  edition. 

In  the  discussion  of  injuries  of  the  pelvic  floor  he  has  en- 
deavored to  rearrange  the  varieties  so  that  they  could  be  more 
clearly  comprehended.  The  surgical  treatment  has  been  simplified 
and  otherwise  improved,  and  more  fully  illustrated  by  drawings 
from  the  living  subject  and  the  cadaver. 

Yaginal  and  abdominal  hysterectomy  have  been  brought  fully 
up  to  date,  and  complete  descriptions  and  illustrations  given  of 
the  approved  methods  of  performing  these  operations. 

The  control  of  haemorrhage  in  all  surgical  procedures  by  com- 
pression and  electric  heat  has  been  made  practical  and  perfect  in  all 
its  details,  so  that  it  now  in  the  author's  practice  takes  the  place 
of  the  ligature.  This  contribution  to  surgery  is  believed  to  be  of 
great  value  not  alone  to  the  gynecologist,  but  to  the  general  sur- 
geon as  well. 

Tlie  surgical  treatment  of  uterine  displacements  is  fully  consid- 
ered and  its  true  value  estimated. 

The  use  of  the  endoscope  and  cystoscope  is  so  described  as  to 
bring  these  instruments  more  completely  within  the  grasp  of  the 


vi  DISEASES  OF   WOMEN. 

general  practitioner,  thus  enabling  him  to  make  diagnoses  other- 
wise impossible. 

The  illustrations  have  been  in  charge  of  Robert  L.  Dickinson, 
M,  D.,  who  has  given  up  much  time  to  the  development  of  accurate 
and  artistic  drawing  of  medical  subjects. 

Prof.  Joseph  H.  Raymond,  who  is  associated  with  the  author  in 
teaching  gynecology,  has  had  entire  charge  of  carrying  the  work 
through  the  press. 

To  these  gentlemen,  and  to  the  profession  at  large,  sincere  thanks 

are  here  tendered  by 

The  Author. 


PEEFAOE  TO  THE  SECOND  EDITIO:^. 


The  demand  for  a  second  edition  of  this  work,  and  the  fact  that 
it  is  used  as  a  text  book  in  many  of  the  leading  medical  schools,  are 
very  gratifying  to  the  author,  who  takes  this  opportunity  to  thank 
the  members  of  the  medical  profession  for  this  evidence  of  their 
approbation. 

Every  eifort  has  been  made  to  improve  this  edition  by  a  thor- 
ough revision  and  the  addition  of  much  new  material. 

New  chapters  have  been  added  on  ectopic  gestation,  diseases 
and  injuries  of  the  ureters,  vesical  hernia  and  its  surgical  treatment, 
and  the  latest  views  of  the  author  have  been  given  in  the  discussion 
of  laparotomy,  ovaritis,  and  injuries  of  the  cervix  uteri  and  pel- 
vic floor. 

The  publishers  have,  at  great  expense,  produced  a  large  number 
of  new  and  handsome  illustrations,  and  in  every  respect  have  made 
the  work  a  perfect  sample  of  their  art. 

The  Author. 

April  15,  1892. 


PREFACE. 


This  book  was  written  for  tlie  purpose  of  bringing  together 
the  f ullj  matured  and  essential  facts  in  tlie  science  and  art  of  gyne- 
cology, so  ari'anged  as  to  meet  the  requirements  of  the  student  of 
medicine,  and  be  convenient  to  tlie  practitioner  for  reference.  In 
the  plan  adopted,  the  diseases  peculiar  to  women  are,  as  far  as 
possible,  divided  into  three  classes.  The  first  class  comprises  those 
which  occur  between  birth  and  puberty ;  the  second,  those  between 
puberty  and  the  menopause ;  and  the  third,  those  which  come  after 
the  menopause. 

Each  subject  is  briefly  described,  and  histories  of  cases,  typical 
and  complicated,  are  given  as  illustrative  of  the  disease  or  injury 
under  consideration,  together  with  the  author's  method  of  treat- 
ment. The  number  of  illustrative  cases  given  depends  upon  the 
practical  importance  of  the  subject  and  the  ability  to  make  it  more 
plain  by  the  use  of  illustrations. 

In  carrying  out  this  plan,  the  history  of  gynecology  and  the 
discussion  of  all  unsettled  questions  have  been  omitted,  as  being  at 
variance  with  the  plan  adopted. 

Credit  has  been  given  as  far  as  possible  to  those  who  have 
made  original  discoveries,  but  a  vast  number  of  original  workers 
have  been  passed  unnoticed  for  want  of  time  and  space  even  to 
name  them. 

To  the  medical  student,  history  has  no  value  until  he  has 
mastered  the  rudiments  of  the  science  and  the  art,  and  the  prac- 
titioner can  find  in  the  works  of  reference  all  the  historical  facts 
which  he  may  seek. 


X  PREFACE. 

The  author  has  ventured  to  give  his  own  views  and  methods 
pertaining  to  practical  matters,  believing  that  while  they  may  differ 
to  some  extent  from  the  general  literature  of  the  day,  they  will 
be  found  reliable  in  practice  and  may  be  of  interest  to  the  spe- 
cialist. 

Marginal  references  have  not  been  made,  because  all  selections 
from  the  literature  that  have  been  incorporated  in  this  work  are 
those  already  well  established  and  familiar  to  the  gynecologist, 
and  foot-notes  only  embarrass  the  reader  who  is  seeking  for  the 
facts  alone. 

Acknowledgments  are  due  to  my  associates  —  Dr.  J.  H.  Ray- 
mond, who  has  rendered  valuable  aid  in  the  preparation  of  the 
work,  and  Dr.  R.  L.  Dickinson,  who  has  made  the  drawings  for 
the  original   illustrations. 

The  Author. 


TABLE  OF  CONTEJ^TS. 


CHAPTER  PAGE 

I. — Methods  of  Observation       ......  1 

II. — Development  op  the  Fallopian  Tubes,  Uterus,  and  Vagina  .  22 

III. — Menstruation  and  its  Derangements  and  Chlorosis    .           .  30 
IV. — Flexions  of  the  Uterus       .            .           .           .           .           .54 

V. — Diseases  of  the  External  Organs  of  Generation        .           .  77 

VI. — Diseases  of  the  Vagina        ......  100 

VII. — Injuries  to  the  Pelvic  Floor  from  Parturition  and  other 

Causes            ........  116 

VIII. — Fistula  in  Ano  and  Coccyodynia    .....  167 

IX. — Inflammatory  Affections  of  the  Uterus            .           .           .  177 

X. — Corporeal  Endometritis       ......  207 

XI. — Subinvolution  .                       ......  219 

XII. — Sclerosis  of  the  Uterus      ......  225 

XIII. — Membranous  Dysmenorrhcea            .....  234 

XIV. — Lacerations  of  the  Cervix  Uteri  .....  247 

XV. — Cicatrices  of  the  Cervix  Uteri  and  Vagina     .           .            .  264 

XVI. — Inversion  of  the  Uterus      ......  271 

XVII. — Dislocations  op  the  Uterus            .....  284 

XVIII. — Retroversion  of  the  Uterus           .....  310 

XIX. — Abuse  of  Pessaries    .......  342 

XX. — Hypertrophy  of  the  Cervix  Uteri            ....  351 

XXI. — Fibroma  of  the  Uterus        ......  856 

XXII. — Malignant  Disease  of  the  Uterus            ....  403 

XXIII.— The  Menopause  .  .  .  .  .  .  .439 

XXIV. — Senile  Endometritis   .......  458 

XXV. — Diseases  of  the  Ovaries       ......  469 

XXVI. — Diseases  of  the  Ovaries  (Continued)         ....  485 

XXVII. — Neoplasms  of  the  Ovaries    ......  506 

XXVIII. — Cystic   Tumors   of  the   Ovaries — Symptomatology  and  Phys- 
ical Signs      .            .           .           .           ,           .           .           .  523 

XXIX.— Ovariotomy       ........  544 


xii  DISEASES  OP   WOMEN. 

CHAPTER  PAGE 

XXX. — Illustrative  Cases  of  Ovarian  Neoplasms       .           .           .  568 

XXXI. — Diseases  of  the  Fallopian  Tubes           ....  586 

XXXII. — Pelvic  Cellulitis     .......  596 

XXXIII. — Pelvic  Peritonitis  .......  620 

XXXIV. — Pelvic  Hematocele            ......  637 

XXXV. — Ectopic  Gestation    .......  649 

XXXVI. — Diseases  of  the  Urinary  Organs — Anatomy  and  Develop- 
ment of  the  Bladder  and  Urethra  ....  659 

XXXVII. — Malformations  of  the  Bladder  and  Urethra            .           .  672 

XXXVIII. — Function  of  the  Bladder  ......  697 

XXXIX. — Functional  Diseases  of  the  Bladder    ....  703 

XL.— Functional  Diseases  of  the  Bladder  {Continued)       .           .  723 

XLI. — Methods  of  Exploration  of  the  Bladder  and  Urethra       .  743 

XLII. — Organic  Diseases  of  the  Bladder           ....  754 

XLIII. — Organic  Diseases  of  the  Bladder  {Continued) — Treatment  of 
Cystitis — Croupous    and    Diphtheritic    Cystitis — Cystitis 

with  Epidermoid  Concretions  .....  788 

XLIV. — Non-Inflammatory   Diseases   of   the   Bladder — Dislocation 

OF  THE  Bladder    .......  812 

XLV. — Foreign  Bodies  in  the  Bladder  .....  831 

XLVI. — Rupture  op  the  Bladder  ......  847 

XLVII. — Neoplasms,  Hyperplasia,  and  Atrophy  of  the  Bladder       .  858 
XLVIII. — Patency  of  Gartner's  Duct — Diseases  of  the  Urethra  and 

Urethral  Glands            ......  873 

XLIX. — Dilatation,  Dislocation,  and  Prolapsus  of  the  Urethra     .  908 
L. — Stricture,  Foreign  Bodies,  and  Incomplete  Fistula  of  the 

Urethra     ........  927 

LI. — Diseases  of  the  Glands  of  the  Female  Urethra       .           .  938 

LII. — Vesical  and  Urethral  Fistula  .....  951 

LIII. — Diseases  and  Injuries  of  the  Ureters  ....  968 


INDEX  TO  ILLUSTRATIOI^S. 


FIO. 
1. 

2. 
3. 
4. 
5. 


9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
18a 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
36. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
34(1, 
35. 
36. 
37. 
38. 


Examining  table 

Bimanual  examination . 

Sims's  speculum 

Cusco's  bivalve  speculum 

Sims's  position,  seen  from  above 

Nurse  holding  Sims's  speculum 

The  movements  of  the  speculum — first  movement 

"  "  — second  movement 

"  "  — third  movement 

Hunter's  depressor 
Sims's  probe 
Whalebone  sound 
Jenks's  sound 
Skene's  curette 
Hanks's  dilator 
Goodell's  dilator 
Sponge  tents 
Tupelo  tents 
.  Ether  inhaler 
Miiller's  ducts 
Coalescence  of  ducts 
Disappearance  of  septum 
Appearance  of  fundus  and  eemx 
Infantile  uterus  (Winckel) 
Palma  plicata     . 
Infantile  uterus,  antero-posterior  section,  scant  invagination 
Virgin  uterus  (Sappey) — anterior  view 

"  "       — median  section 

"  "       — transverse  section 

Double  uterus  and  vagina  (Eisenmann) 
Uterus  unicornis  (Pole) 
Uterus  bicomis  unicollis  (Winckel) 
Uterus  bifundalis  unicollis  (Courty) 
Uterus  duplex  (Cruveilhier) 
Double  uterus     . 

,  Anteflexion  of  cei'vix — first  variety 
Anteflexion  of  body  of  uterus — second  variety 
Anteflexion  of  body  and  cervix — third  variety 
Operation  for  imperfect  invagination ;  the  incision 

"  "  "  sutures  in  position 

xiii 


9 
11 
11 
12 
12 
13 
18 
14 
14 
15 
15 
15 
16 
17 
17 
18 
18 
19 
22 
22 
23 
22 
23 
23 
23 
24 
24 
24 
35 
36 
26 
27 
37 
29 
57 
58 
58 
66 
66 


XIV 


DISEASES  OF  WOMEN. 


FIG. 

39.  Elliott's  uterine  adjuster 

40.  Glass  stem,  with  soft-rubber  base 

41.  Extreme  anteflexion 

42.  Skene's  hysterotome 
48.  External  genitals  of  a  woman  who  has  borne  children 

44.  The  superficial  veins  of  the  perinajum  (Savage) 

45.  External  genitals  of  a  virgin    . 

46.  Cribriform  hymen  .... 

47.  Annular  hymen  ..... 

48.  Fimbriate  hymen  .... 

49.  Rectum  continuous  with  allantois  (bladder)  and  duct  of  Miiller  (vagina) 

(Schroeder)  ..... 

50.  The  depression  has  extended  inward  (Schroeder) 

51.  The  cloaca  is  dividing  (Schroeder) 

52.  The  perineal  body  is  completely  formed  (Schroeder) 

53.  The  upper  part  has  contracted  (Schroeder)    . 

54.  Spurious  hermaphroditism  (Simpson) . 

55.  Length  of  vagina  .... 

56.  Triangular  shape  of  perineal  body 

57.  Sims's  vaginal  dilator    .... 

58.  The  levator  ani  ..... 

59.  The  muscles  of  the  pelvic  floor 

60.  Diagrammatic  sagittal  section  of  the  female  pelvis 

61.  Tlie  pelvic  floor  a  suspension  bridge    . 

62.  So-called  rectocele  .... 

63.  Beginning  atrophy  of  perineal  body  in  median  line 

64.  Atrophy  in  median  line,  with  sagging  of  posterior  vaginal  wall 

65.  Sagging  of  the  pelvic  floor 

66.  Diagram  of  the  sweep  of  the  suture     . 

67.  68.  Sutures  properly  and  improperly  introduced 

69.  Peaslee's  needle ..... 

70.  Tissue  forceps    ..... 

71.  Emmet's  curved  scissors 

72.  Emmet's  scissors  .... 

73.  First  step  of  perineorrhaphy,  denudation  begun 

74.  Second  step,  continuing  the  strip 

75.  Vivifying  complete        .... 

76.  Needle-forceps    ..... 

77.  Stitch  in  place    ..... 

78.  The  stitches  in  place      .... 

79.  Laceration  with  rectocele 

80.  Perineal  body  restored  (profile  view)    . 

81.  Scissors  for  removing  sutures  . 

82.  Complete  laceration  of  perinajum  and  sphincter  ani 

83.  do.  operation ;  denudation  completed 

84.  do.  "  sutures  in  rectal  wall  introduced 

85.  do.  "  rectal  sutures  tied ;  remaining  sutures  placed 

86.  Haeraorrhoid  clamp 

87.  Hard-rubber  rectal  tube 

88.  Denudation  for  restoration  of  periuffium 

89.  Sutures  in  place .... 

90.  The  operation  for  fistula  in  ano  , 


INDEX  TO  ILLUSTRATIONS. 


XV 


FIG. 
91. 

92. 
93. 
94. 
95. 
96. 
97. 


99. 
100. 
101. 
103. 
103, 
105. 
106. 
107. 

108. 
109. 
110. 
111. 
113. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
130. 
121. 
133. 
133, 
125, 
127. 
138. 
139. 
130. 
131. 
132. 
133. 
134. 
135. 
136. 
137. 
138. 
139. 
140. 

141. 
143. 


Mold  of  uterine  cavity  in  the  virgin  (Guyon) 
"  "  "  "      multipara  (Guyon) 

Section  of  mucous  membrane  of  uterus 
"       through  corpus  uteri  of  an  infant    . 
'•  '•  "  "     of  a  woman  aged  eighty-three 

One  of  the  median  columns  in  the  cervical  canal  (Courty) 

Section  through  the  mucous  membrane  of  cervix  showing  cystic  degen- 
eration       ...... 

Elongation  of  the  cervix  (Wincltel)     . 

Hypertrophy  of  the  body  of  uterus  (Winckel) 

General  enlargement  of  uterus  (Winckel) 

Skene's  instillation  tube  .... 

Sims's  curette  ...... 

104.  The  two  sides  of  a  half  membrane  from  a  multipara 

Half  a  membrane  from  a  virgin 

A  cast  from  a  virgin    ..... 

Fragments  of  membrane  in  the  condition  in  which  they  are  often  ex- 
pelled        ...... 

A  cast  which  might  be  taken  for  a  product  of  conception 

Bilateral  laceration  ;  unequal  division  of  the  cervix 

Bilateral  laceration,  with  thickening  of  the  everted  lips 

Extensive  multiple  lacerations 

Multiple  incomplete  lacerations 

Incomplete  bilateral  laceration 

"  '•  "         in  section 

Crescentic  laceration    ..... 

Skene's  hawk-bill  scissors        .... 

Operation  for  laceration  of  cervix ;  denudation  complete 

Skene's  triangular  needles       .... 

Counter-pressure  instrument  .... 

Operation  for  laceration ;  sutures  in  position 
"  "       tied 

Removal  of  crescentic-shaped  piece  (seen  in  section) 

124.  Method  of  bringing  the  sides  of  the  section  together 

126.  Another  method  of  closing  the  gap 

Partial  inversion  (Thomas) 

Complete  inversion  (Thomas) . 

Polypus  simulating  partial  inversion  (Thomas) 

Polypus  simulating  complete  inversion  (Thomas) 

Byrne's  method  of  reduction  of  inversion 

Cup  pessary  to  exercise  gradual  pressure  (Thomas) 

Replacement  of  uterus  by  dilatation  through  abdomen  (Thomas). 

Section  of  pelvis  showing  its  inclination  and  tlie  axis  of  the  inlet , 

The  normal  range  of  the  uterine  axis  (Van  der  Warker) 

Diagram  of  the  uterine  ligaments       .... 

Section  through  right  broad  ligament 

Section  of  pelvis,  with  the  slings  of  the  uterus 

Diagram  of  the  uterus  slung  between  the  broad  ligaments 

The  normal  inclination  of  the  pelvis  and  the  transmission  of  force  from 
above  ..... 

The  three  degrees  of  prolapsus 

Prolapsus  uteri  with  cystocele 


XVI 


DISEASES  OF   WOMEN. 


FIG. 

143.  The  shallow  pelvis  with  lessened  inclination  of  brim 

144.  Increased  inclination  of  inlet 

145.  Uterus  replaced,  with  pessary  in  position 

146.  Stem  pessary,  modification  of  Cutter's 

147.  The  three  degrees  of  retroversion 

148.  Retroversion  of  the  second  degree 

149.  Retroversion  with  imperfect  invagination  of  cervix 

150.  Apparent  imperfect  invagination 

151.  The  same  uterus  with  its  lips  drawn  back  into  place 

152.  The  three  steps  in  replacing  the  retro  verted  uterus  by  means  of  sponge 

holders       ....... 

158.  Albert  Smith  pessary  ...... 

154.  Method  of  measuring  the  length  of  the  pessary 

155.  Diagram  of  pessary  in  situ  on  looking  through  Sims's  speculum 

156.  Slight  invagination  of  cervix  posteriorly  with  suitable  pessary 

157.  Decided  invagination  of  cervix  posteriorly  fitted  with  a  suitable  pessary 

158.  What  the  pessary  does  not  do  .... 

159.  How  the  pessary  acts  ...... 

160.  Second  step ;  the  uterus  falls  into  the  pessary 

161.  The  knee-chest  position  ..... 
163.  Ventral  suspension       ...... 

163.  Fibroid  on  posterior  wall  of  uterus  simulating  retroflexion 

164.  Prolapsed  and  adherent  ovary  simulating  retroversion 

165.  Overcurved  pessary  making  pressure  on  angle 

166.  Extreme  retroflexion  (Barnes)  .... 

167.  Uterus  with  defective  walls;  the  supra-vaginal  portion  of  the 

elongated  (after  Winckel)  .... 

168.  Stem  of  pessary  ulcerating  through  cervix  . 

169.  Stem  cutting  through  body  of  uterus 

170.  High  rectoeele  due  to  improper  pessary 

171.  Displacement  caused  by  a  badly  adjusted  pessary    . 
173.  IIyi)ertro[)hy  of  the  cervix       ..... 

173.  The  first  stop;  splitting  the  cervix    .... 

174.  The  double  flaps  of  the  amputation   .... 

175.  Diagram  of  the  pieces  removed  .... 

176.  The  sutures  in  place    ...... 

177.  The  sutures  tied  ...... 

178.  179.  Interstitial  fibromata  (Winckel). 

180.  Subperitoneal  and  submucous  fibromata  (Winckel)  . 

181,  182.  Enlargement  due  to  subinvolution  compared  with  that  from  growth 

of  a  fibroma  (after  Winckel) 

183.  Uterine  electrode         ..... 

184.  ficraseur  ...... 

185.  Wall  of  uterus  caught  in  ecrascur-wire  and  removed 

186.  Abdominal  hysterectomy  (Kelly) ;  line  of  incision    . 

187.  "  "  "    ovarian  vessels  and  round  ligament  tied 

188.  Cancer  of  both  lips  (Winckel)  .... 

189.  Cleveland  ligature  forceps      ..... 

190.  Vaginal  hysterectomy — clamp  operation  :  Specnhim  in  place 

191.  do.  Cervix  severed  from  vaginal  wall     . 

192.  do.  Forceps  pushed  through  pouch  of  Douglas 

193.  do.  Forceps  draws  tube  forward 


INDEX  TO  ILLUSTRATIONS. 


xvn 


FIG.  PAGE 

194.  Vaginal  hysterectomy — clamp  operation :  Forceps  turns  broad  ligament  .  425 

195.  do.             Tube  and  ovary  rolled  forward        ....  425 
19G.              do.             Uterine  artery  clamped        .....  425 

197.  do.             Placing  gauze             ......  485 

198.  Vaginal  hysterectomy  by  morcellement          .....  426 

199.  Vaginal  hysterectomy  by  author's  electric  haemostatic  forceps :  Beef  mus- 

cle seized  in  forceps       .....  428 

200.  do.  Artery  closed  .  .  .  .  .  .428 

201-203.      do.  Hemostatic  forceps  .  .  .  .  .  .430 

204.  do.            Transformer  for  heating  forceps     ....  433 

205.  do.            Hand-driven  dynamos          .....  434 

206.  do.            Cautery  incisions  about  cervix        ....  435 

207.  do.            Vagina  and  wound  after  removal  of  uterus           .            .  485 

208.  The  fundus  uteri  and  ovaries  seen  through  the  pelvic  brim  (His) .            .  469 

209.  The  ovary  and  its  ligaments  (Henle)  ......  470 

210.  The  ovarian,  uterine,  and  vaginal  arteries  (Hyrtl)   ....  471 

211.  Cyst-regions  of  ovary  (Bland-Sutton)            .....  473 

212.  Section  of  the  ovary  of  a  bitch  (Waldeyer)    .....  475 

213.  Ovary  displaced  and  bound  down  by  adhesions        *            .            .             .  501 

214.  Left  ovary,  one  large  cyst  (Farre)       ......  508 

215.  Compound  and  proliferating  cyst  (Farre)      .....  509 

216.  Multilocular  cyst  (Hooper)      .  .  .  .  .  .  .510 

217.  Papillary  cystoma  of  ovary  (Winckel)           .....  511 

218.  Dermoid  cyst  of  ovary  (Winckel)        ......  512 

219.  Fibroma  affecting  both  ovaries  (Winckel)    .....  513 

220.  Area  of  dullness  in  large  ovarian  tumor       .....  528 

221.  Area  of  dullness  in  ascites      .......  529 

223.  Cautery  clamp              ........  548 

223.  Keith's  short  compression-forceps     ......  556 

224.  Keith's  long  compression-forceps       ......  556 

225.  Keith's  needle  .........  557 

226.  Keith's  ligature-forceps           .......  557 

227.  Keith's  modification  of  Spencer  Wells's  clamp         ....  557 

228.  Position  of  operator,  assistants,  and  accessories  in  ovariotomy       .            .  558 

229.  Diagrammatic  transverse  section  of  the  pelvis  (Luschka)  .            .            .  596 

230.  Section  through  sacrum,  symphysis,  and  ischia       ....  597 

231.  Pelvic  abscess  opening  obliquely  downward             ....  598 

232.  Pelvic  abscess  opening  obliquely  upward      .....  598 

233.  The  pelvic  peritonaeum,  looking  into  the  brim         ....  620 

234.  The  reflections  and  pouches  of  the  pelvic  peritonaeum  (Hodge)     .            .  621 

235.  Retroverted  uterus  bound  back  by  peritoneal  adhesions  (Winckel)           .  623 

236.  Subperitoneal  pelvic  hsematocele       ......  637 

237.  Intra-peritoneal  pelvic  haematocele   ......  638 

238.  Diagram  of  the  bladder  to  show  corpus  and  fundus            .            .            .  660 
230.  Base  and  neck  of  the  bladder  (Savage)           .....  663 

240.  Urethra  laid  open  with  probes  distending  Skene's  glands  (posterior  wall 

divided)     .........  664 

241.  Urethra  laid  open  with  probes  in  Skene's  glands  (anterior  wall  divided)  .  664 

242.  Transverse  section  of  urethra  with  gland  on  either  side     .            .            .  665 

243.  Longitudinal  section  of  urethral  glands        .....  666 

244.  The  meatus  everted,  showing  the  mouths  of  the  glands      .            .            .  667 

245.  The  relations  of  the  ureters  (Garrigues)        .....  670 


xvm 


DISEASES  OF   WOMEN. 


FIG. 

246.  Extroversion  of  the  bladder   .... 

247.  Linear  cicatrix  ..... 

248.  Bladder  covered  by  deep  flaps 

249.  Diagram  of  the  result  of  the  operation 
250-252.  Slcene's  endoscope  .... 

253.  Urethroscope  with  electric  light 

254.  Principle  of  the  Xitze-Leiter  cystoscope 

255.  Diagram  of  cystoscope  .... 

256.  Leiter  cystoscope         ..... 

257.  Skene's  modification  of  cystoscope    . 

258.  "  "  "  "  for  ureteral  catheterization 

259.  Skene's  bivalve  urethral  speculum    . 

260.  Fountain-syringe  for  washing  bladder 

261.  Skene's  instillation-tube  .... 

262.  Skene's  urinal  cup-pessary      .... 

263.  Holt's  catheter,  with  its  modification 

264.  Skene's  modification  of  Goodman's  self-retaining  catheter 

265.  Retroversion  of  the  gravid  uterus  (Schatz)   . 

266.  Skene's  pessaiy  for  prolapsus  of  the  bladder 

267.  Pessary  holding  up  the  bladder 

268.  Modification  of  the  retroversion  pessary,  used  in  prolapsus  of  the 

269.  Forward  transposition  of  the  uterus  . 

270.  Retrocession  of  the  uterus      .... 

271.  Skene's  reflux  catheter  .... 

272.  Skene's  fissure  probe  and  knife 

273.  Skene's  urethral  speculum      .... 

274.  Skene's  modification  of  Polsom's  nasal  speculum    . 

275.  Allen's  polypus  forceps  .... 

276.  Blake's  polypus  snare  ..... 

277.  Dilatation  of  middle  third  of  the  urethra     . 

278.  Skene's  button-hole  scissors    .... 

279.  Dislocation  of  upper  third  of  urethra 

280.  Complete  dislocation  with  dilatation 

283.  Sims's  tenaculum         ..... 

284.  Operation  for  vesico- vaginal  fistula ;  paring  the  edges 

285.  Sims's  sponge-holder  ..... 

286.  Emmet's  needles  ..... 

287.  Curved  track  of  the  needle     .... 

288.  Operation  for  vesico-vaginal  fistula ;  the  sutures  in  place 

289.  Two  sutures  tied  ..... 

290.  Kelly's  ureteral  catheter         .... 


bladder 


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881 
892 
903 
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904 
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959 
960 


Plate  I.  Operation  for  laceration  of  cervix  uteri. 

II.  "Vaginal  hysterectomy  with  the  author's  hajmostatic  cautery  forceps. 

III.  Abdominal  hysterectomy  with  the  author's  hajmostatic  cautery  forceps. 

IV.  Inflammation  of  the  urethral  glands. 

IV.  Operation  for  prolapsus  of  bladder  and  urethra. 

Note. — All  illustrations  not  credited  are  from  original  drawings  by  Robert  L. 
Dickinson,  M.  D.,  or  were  prepared  under  his  supervision,  excepting  cuts  of  instru- 
ments and  Figs.  93,  94,  95,  97,  242,  and  243,  by  J.  M.  Van  Cott,  M.  D.,  and  Figs. 
240  and  241,  by  A.  U.  P.  Leuf,  M.  D. 


DISEASES   OF  WOMEN. 


CHAPTER  I. 

METHODS    OF    OBSERVATION. 

A  THOROUGH  familiarity  with  the  means  and  methods  of  investi- 
gation is  the  first  requisite  in  acquiring  knowledge.  The  art  of 
observation,  which  is  simply  the  systematic  use  of  the  mental  and 
physical  faculties  to  obtain  facts,  should  be  made  an  essential  part  of 
the  preliminary  training  of  every  student  of  medicine.  From  this 
point  of  view,  the  subject  which  we  have  to  consider  resolves  itself 
into  two  divisions :  first,  the  ways  and  means  of  investigation ;  and, 
second,  the  objects  to  be  studied. 

Before  approaching  the  study  of  gynecology,  it  is  taken  for 
granted  that  much  experience  and  practice  have  been  attained  by 
the  student  in  the  art  of  investigation.  The  experience  of  every- 
day life,  from  infancy  onward,  and  the  ordinary  school  education 
obtained  before  beginning  the  study  of  medicine,  tend  to  develop  and 
cultivate  the  perceptive  faculties.  Still,  the  physician  and  surgeon 
require  special  training  in  the  art  of  observation.  To  accurately  note 
the  structure,  form,  color,  general  proportions,  and  expressions  of 
the  human  body  in  health,  is  the  first  lesson  which  every  student  of 
medicine  should  learn.  This  is  the  most  important  step  toward  the 
attainment  of  a  practical  knowledge  regarding  the  functions  of  the 
human  body,  and  its  deformities,  diseases,  and  injuries.  The  correct, 
rapid,  and  thorough  observer  has  from  the  outset  great  advantages. 
Important  and  necessary  as  this  branch  of  education  is,  it  is  almost 
wholly  neglected  in  schools  and  colleges.  The  chief  occupation  of 
teachers  appears  to  be  to  impart  knowledge  already  in  existence, 
rather  than  to  qualify  the  student  to  observe  and  think  for  himself. 

Special  attention  should  be  given  to  this  art  of  observation,  be- 
cause it  is  the  key  to  science  and  the  first  exercise  in  practice.  The 
systematic  way  in  which  knowledge  is  presented  in  books  and  by 
oral  instruction  enables  the  student  to  acquire  facts  in  all  branches 
2  1 


2  DISEASES  OF  WOMEN. 

of  learning,  and  to  classify  them.  The  mental  training  obtained  in 
the  study  of  mathematics  and  logic  prepares  men  to  make  reasonable 
deductions  from  the  facts  obtained ;  but  in  institutions  of  learning, 
thorough  training  in  the  art  of  observation  is  seldom  given. 

This  lack  of  preliminary  education  adds  greatly  to  the  labors  of 
the  student,  because  he  is  obliged  to  acquire  knowledge  while  he  is 
not  in  possession  of  the  means  of  obtaining  it,  and  it  is  mainly  be- 
cause of  this  defect  that  practitioners  of  medicine  are  led  into  error 
in  making  diagnoses.  They  fail  to  observe  all  the  facts,  and  hence 
their  deductions  are  liable  to  be  incorrect. 

Acute,  clear  perception  is  a  gift  which  all  do  not  possess  in  a 
high  degree,  but  it  can  be  cultivated  by  those  of  ordinary  intelli- 
gence, and  it  should  be  by  those  who  intend  to  practice  medicine. 
The  practical  study  of  the  elements  of  natural  science,  which  should 
constitute  a  large  share  of  the  early  education  of  those  destined  for 
the  profession  of  medicine,  aids  much  in  cultivating  the  faculties 
concerned  in  observation.  So  also  the  arts,  especially  drawing, 
painting,  and  sculpture,  help  to  qualify  for  the  actual  in  professional 
life.  The  trained  eye  and  hand  of  the  artist  are  most  valuable  in 
acquiring  the  art  of  medicine  and  surgery,  and  a  share  of  the  days 
of  youth  spent  at  an  art-school  will  save  much  time  and  perplexity 
in  the  medical  school  as  well  as  in  subsequent  professional  life. 

The  first  lesson  is  to  obtain  a  familiarity  with  the  general  appear- 
ance of  the  body  in  health,  its  structure  and  the  uses  of  the  various 
organs,  the  process  of  development,  the  slight  deviations  from  the 
ideal  or  highest  type  which  occur  within  the  range  of  health,  and 
finally  the  relations  of  the  being  to  his  environment  or  conditions  of 
life.  A  portion  of  this  subject  will  be  fully  discussed  in  the  chapter 
on  the  development  and  structure  of  the  sexual  organs  of  woman,  and 
the  conditions  of  life  which  are  suitable  to  her  development,  growth, 
and  maintenance.  Subsequently  the  derangements  of  the  body  from 
disease  and  injury  will  come  in  for  the  greater  portion  of  time  and 
attention.  Here  it  is  that  the  highest  perceptive  power  is  needed, 
and  the  most  painstaking  attention  to  observation. 

The  fact  should  be  kept  clearly  in  mind  that  a  knowledge  of  the 
science  of  medicine  does  not  give  skill  in  the  art  of  practice,  how- 
ever much  it  may  help  in  acquiring  that  art.  Men  profoundly 
versed  in  the  science  of  medicine  may  be  poor  practitioners ;  and 
others,  whose  knowledge  of  the  science  is  very  limited,  may  attain 
some  reputation  in  practice ;  but  the  best  (qualified  physician  is  he 
who  knows  most  of  both  the  science  and  the  art.  The  subject  for 
present  consideration  is  the  method  of  investigation  to  be  adopted 


METHODS   OP   OBSERVATION.  3 

in  practicing  the  art  of  gynecology.  Before  beginning  the  actual 
work  of  examining  patients,  it  is  necessary  to  know  how  to  do  so. 

There  are  several  methods  of  investigating  the  sick  and  injured 
given  in  text-books  and  taught  in  the  medical  schools,  but  most  of 
these  are  better  adapted  to  general  practice  than  to  special  depart- 
ments of  medicine.  The  methods  which  I  desire  to  present  here 
are  circumscribed,  and  perhaps  less  complicated,  because  they  are 
limited  to  the  diseases  peculiar  to  women. 

In  examining  patients  it  is  well  to  first  settle  definitely  in  the  mind 
the  object  to  be  attained  and  how  to  attain  it.  Some  rational  system 
of  investigation  should  be  mastered  in  all  its  details  before  undertak- 
ing actual  practice.  To  engage  in  clinical  study  without  such  prepara- 
tion is  like  trying  to  read  a  language  without  knowing  its  alphabet. 

The  system  advised  is  :  first,  to  obtain  all  the  facts  regarding  the 
case  in  hand ;  second,  to  arrange  these  facts  in  their  natural  relation 
to  one  another ;  and,  finally,  to  make  deductions  from  the  data  thus 
obtained.  These  suggestions  will  be  easily  remembered  in  the  follow- 
ing order  and  association :  observation,  classification  of  things  observed, 
and  conditions  indicated  by  the  sum  of  the  information  obtained. 

The  examination  of  a  patient  should  begin  by  a  general  inspec- 
tion ;  and,  in  order  to  make  that  inquiry  complete  and  profitable,, 
certain  questions  should  be  raised  in  the  mind  of  the  examiner ;  such, 
for  example,  as.  What  is  the  general  appearance  of  the  patient  under 
observation  ?  What  size  ?  Regular  or  defective  in  general  outline  ? 
Lean  or  corpulent  ?  What  temperament  ?  Is  the  face  pale  or  flushed  ? 
Languid  or  vigorous  ?  Sad  or  cheerful  ?  Calm  or  excited  ?  Intel- 
ligent or  stupid  ?  What  diathesis  is  indicated,  if  any  ?  In  short,^ 
does  the  general  physiognomy  indicate  health  or  disease  ? 

All  these  interrogations  are  made  while  looking  critically  at  the 
patient.  There  are  so  many  questions  to  be  answered  in  this  con- 
nection, that  one  may  find  some  difiiculty  in  promptly  remembering 
them ;  but  by  constant  practice  the  mind  and  eye  can  be  trained  to 
take  advantage  of  a  rule  of  observation  employed  by  critical  investi- 
gators in  other  arts,  which  is  this  :  having  a  type  of  normal  organiza- 
tion in  mind,  the  observer  is  able  to  scan  a  given  case,  and  detect  any 
deviation  from  that  standard  of  healthy  formation  and  appearance. 
The  artist,  in  looking  at  a  picture  or  statue,  does  not  necessarily 
question  every  line  of  the  drawing  or  form  by  itself,  but  his  trained 
eye  catches  any  defects  that  there  may  be  in  the  work  before  him. 

The  classification  of  facts  is  simply  putting  together  those  which 
are  similar  in  character.  The  arrangement  of  material  things  in 
groups  is  familiar  to  all.    A  well-arranged  library,  in  which  all  books 


4:  DISEASES  OF  WOMEN. 

pertaining  to  a  given  subject  are  placed  side  by  side,  is  a  fair  illus- 
tration of  this  kind  of  classification.  Facts  and  ideas  can  be  arranged 
in  the  mind  upon  precisely  the  same  principle.  The  advantage  of 
classification  is  that  it  aids  comprehension  and  memory.  By  recall- 
ing one  group  of  facts  which  have  been  associated  in  the  mind,  the 
rest  will  follow  in  easy  and  natural  order.  There  are  two  methods 
of  classifying  the  information  contained  in  the  clinical  history'  of  a 
patient.  One  is  to  obtain  all  the  facts  possible,  and  then  to  arrange 
them  in  order.  The  other  is  to  classify  them  at  each  step  of  the 
examination.  The  former  method  requires  a  mental  grasp  and 
tenacity  which  few  possess,  and  therefore  1  would  advise  the  latter. 

The  information  obtained  by  inspection  may  be  classed  under  four 
heads  :  1.  The  original  character  of  the  organization,  M'hether  perfect 
or  imperfect  in  structure  and  function.  2.  If  imperfect,  whether  from 
imperfect  development,  causing  lesions  of  form  or  lesions  of  structure, 
or  from  inherited  or  acquired  disease,  and  inherited  tendencies  to  dis- 
ease, known  as  diathesis.  3.  Evidences  of  disease,  expressed  in  the  face, 
either  acute  or  chronic.  4.  The  temperament ;  which  simply  means 
the  preponderance  of  a  certain  portion  or  portions  of  the  organization. 

To  illustrate  the  value  of  this  process  of  general  inspection  of 
patients,  the  partial  histor}^  of  a  case  seen  in  private  practice  will 
suffice.  A  lady  called  to  consult  me  regarding  her  son,  a  little  fel- 
low seven  years  of  age.  After  a  very  brief  survey  of  the  patient,  I 
saw  enough  to  satisfy  me  that  he  had  recently  had  scarlatina,  and 
that  when  a  child  he  had  suffered  from  sore  eyes,  and  that  his  father 
had  been  subject  to  rheumatic  pains  in  years  gone  by.  The  mother 
acknowledged  that  I  was  right  in  every  particular.  A  glance  at  the 
boy  showed  that  exfoliation  of  the  cuticle,  which  occurs  after  scar- 
latina, was  still  going  on ;  the  face  was  pale  and  puffy,  indicating 
commencing  dropsy  from  acute  nephritis,  a  sequel  of  the  eruptive 
fever.  I  also  noticed  that  he  had  a  scar  upon  the  cornea  of  each 
eye,  the  result  of  a  former  keratitis.  The  form  of  his  nose  and  the 
character  of  his  teeth  indicated  an  inherited  syphilis ;  and  from  the 
appearance  of  his  mother  and  other  facts  known  to  me,  I  presumed 
that  the  father  was  the  one  who  had  transmitted  the  specific  disease. 

The  age  of  the  patient  should  be  ascertained,  because  that  sug- 
gests the  possible  existence  of  the  diseases  which  are  likely  to  occur 
at  certain  periods  of  life.  Care  should  be  taken  to  compare  the  real 
and  apparent  age,  in  order  to  ascertain  if  the  patient  is  prematurely 
old,  or  well  preserved.  This  interrogation  will  also  serve  to  keep  in 
mind  the  fact  that,  in  early  life,  acute  diseases  prevail,  while  degen- 
erations are  usually  limited  to  advanced  life. 


METHODS  OP   OBSERVATION.  5 

It  is  important  to  know  the  social  relations  of  a  patient — that  is, 
whether  she  is  married  or  single.  If  married,  she  is  liable  to  the 
diseases  and  accidents  attendant  upon  child-bearing.  If  she  has 
never  been  pregnant,  her  sterility  may  have  resulted  either  from 
choice,  or  because  of  some  defect  in  her  organization.  Women  who 
are  single  are,  by  reason  of  that  fact,  limited  in  the  range  of  diseases 
of  their  sexual  organs,  and  this  may  be  taken  for  granted  unless  evi- 
dence to  the  contrary  is  obtained. 

Having  made  a  general  inspection  of  a  given  case,  and  ascer- 
tained the  age  and  social  relations,  an  examination  of  the  various 
portions  of  the  body  should  next  be  made  in  systematic  order.  To 
do  this  conveniently,  one  group  of  organs  or  one  system  should  be 
examined  at  a  time.     The  various  systems  are  classified  as  follows : 

THE   NERVOUS,    NUTRITIVE,    MUSCULAR,   AND   SEXUAL 

SYSTEMS. 

The  first  three  are  subdivided  as  follows  :  The  nervous  has  two 
grand  divisions,  the  cerebro-spinal  and  organic.  The  nutritive  lias 
four  subdivisions,  the  digestive,  circulatory,  lymphatic,  and  excre- 
tory ;  and  the  third  has  the  osseous  and  muscular. 

The  present  purpose  is  to  outline  the  methods  of  investigating 
the  sexual  system,  but,  in  order  to  do  that  successfully,  it  is  necessary 
to  be  able  to  examine  the  whole  body.  'No  one  can  be  a  trustworthy 
specialist  without  having  a  thorough  knowledge  of  the  whole  organi- 
zation. All  the  parts  of  the  body  are  so  bound  together  by  mutual 
relations  that  one  can  not  accurately  diagnosticate  the  diseases  of 
one  portion  without  knowing  the  condition  of  all  the  others.  On 
account  of  that  fact  I  must  refer  to  the  principles  upon  which  the 
examination  is  made  of  parts  other  than  the  sexual  system. 

Briefly,  it  may  be  stated  that  the  two  principal  subjects  of  inquiry 
are  the  condition  of  the  functions  and  the  structure  of  the  organs 
under  examination.  Perverted  function  of  the  cerebro-spinal  divis- 
ion of  the  nervous  system  is  manifested  through  derangements  of 
sensation  and  motion,  and  abnormal  states  of  the  organic  nerves  are 
indicated  when  nutrition  is  deranged,  while  the  organs  of  nutrition 
are  free  from  structural  disease.  The  condition  of  the  circulatory 
system  is  indicated  by  the  color  of  the  skin  and  mucous  membranes, 
the  character  of  the  pulse,  and  the  heart-sounds. 

The  general  nutrition  may  be  estimated  by  the  appetite  for  food, 
the  excretions,  and  the  state  of  the  tissues  generally.  These  are 
meager  hints,  but,  if  kept  in  mind  while  examining  cases  in  the  de- 
partment of  gynecology,  will  guard  against  the  mistake  of  overlook- 


6  DISEASES   OF   WOMEN. 

ing  affections  of  the  general  system,  which  might  modify  or  cause 
diseases  of  the  sexual  system. 

In  applying  the  principles  already  hinted  at  in  the  investigations 
of  special  diseases  of  the  sexual  organs,  we  find  that  morbid  action  is 
manifested  by  symptoms  and  physical  signs.  The  symptoms  may 
be  classed  under  three  heads :  First,  deranged  nerve-action ;  second, 
deranged  functions  of  the  organs  affected  ;  and,  third,  modified  loco- 
motion. 

First  Class  (nerve-symptoms). — Pelvic  pains  not  specially  local- 
ized ;  sacral  pain  ;  pain  of  certain  pelvic  organs ;  pains  beginning 
in  the  pelvis  and  radiating  to  other  parts  of  the  body. 

Second  Class. — Derangements  of  function,  such  as  deranged  men- 
struation ;  sterility  ;  abnormal  discharges ;  deranged  function  of  the 
bladder  and  rectum. 

Third  Class. — Aggravation  of  any  or  all  of  the  above-named 
symptoms,  by  standing,  walking,  or  other  muscular  exercise. 

Keeping  this  classification  in  mind,  questions  will  suggest  them- 
selves, the  answers  to  which  will  determine  the  presence  or  absence 
of  these  symptoms.  One  should  know  the  symptoms  which  belong 
to  a  given  disease,  and  then  ascertain  if  they  are  present  by  asking 
questions  of  the  patient.  Correct  testimony  will  more  surely  be  ob- 
tained in  this  way  than  by  depending  upon  the  voluntary  statements 
of  the  person  examined. 

The  following  plan  will  be  of  service  in  obtaining  the  symp- 
toms referred  to  in  the  three  classes  given  above :  First,  ask  if  the 
patient  has  pain  and  where  it  is  located.  Ascertain  also  if  this  pain 
is  connected  with  any  of  the  functions  of  the  pelvic  organs.  Then 
obtain  the  history  of  the  functions  of  the  sexual  organs,  in  the 
past  and  present.  These  facts  can  be  obtained  from  the  patient 
herself,  aided  perhaps  by  some  one  who  knows  her  well.  Some 
practice  is  necessary  to  acquire  skill  in  taking  testimony,  the  value 
of  which  depends  largely  upon  the  physician's  abilitj'  to  make  the 
patient  answer  his  questions  correctly.  Such  questions  as  the  fol- 
lowing regarding  the  menstrual  function  should  be  asked :  At  what 
age  was  the  menstrual  function  first  established  ?  At  wliat  periods 
of  time  has  it  recurred?  IIow  long  does  it  continue  each  time? 
"What  are  the  quantity  and  character  of  the  flow  ?  Is  it  attended  with 
pain,  and  if  so,  where  is  the  pain  located,  and  at  what  time  does  it 
occur  in  relation  to  the  menstrual  flow  ?  Has  menstruation  always 
been  attended  with  pain,  or  only  for  a  limited  period  in  the  history 
of  that  function  ?  And,  finally,  is  menstruation  attended  with  de- 
rangements of  any  of  the  other  functions  of  the  body  ? 


METHODS  OP   OBSERVATION.  7 

From  the  answers  to  these  questions  two  points  can  be  decided  : 
First,  whether  menstruation  has  been  performed  normally  during 
the  whole  or  part  of  the  patient's  menstrual  period  of  life  ;  and,  sec- 
ond, if  any  derangement  of  that  function  exists,  whether  it  be  in 
character,  recurrence,  duration,  or  quantity. 

Next  in  order  comes  the  history  of  reproduction.  Has  the  pa- 
tient had  children,  and  if  so,  how  many,  and  when  ?  Has  she  mis- 
carried ?  If  she  has,  at  what  period  of  gestation,  and  at  what  time 
in  relation  to  birth  of  living  children  if  she  has  had  any  ?  "Was 
there  anything  abnormal  in  her  pregnancies,  confinement,  or  recov- 
ery from  labor ;  if  so,  what  ?  The  answers  to  these  questions  will 
determine  whether  the  present  conditions  date  back  to  some  of  the 
diseases  or  accidents  of  pregnancy  or  parturition.  If  the  history  so 
far  obtained  indicates  any  disease  or  functional  derangement  of  the 
sexual  organs,  and  there  is  any  accompanying  affection  of  the  general 
system,  the  question  arises,  regarding  the  relations  which  they  sus- 
tain to  one  another.  That  question  can  frequently  be  settled  by 
ascertaining  which  of  the  two  affections,  the  local  or  general,  ap- 
peared first.  The  one  which  precedes  is  frequently  the  cause  of 
that  which  follows. 

Thus  far  we  have  been  dealing  with  symptoms  which,  as  a  rule, 
reveal  only  derangements  of  function.  They  are  but  expressions 
of  disease,  and  do  not  in  all  cases  indicate  the  conditions  of  the 
organization  which  cause  the  derangement  of  function. 

This  brings  us  to  the  final  division  of  our  subject,  viz.,  the  phys- 
ical signs  of  disease.  These  are  the  physical  evidences  of  change  of 
structure.  There  are  exceptions  to  the  general  rule  that  these  phys- 
ical evidences  are  always  present,  but  they  are  few  in  number,  and 
therefore  may  be  omitted  in  our  general  consideration  of  the  subject. 

The  changes  of  structure  and  organization  in  the  sexual  organs, 
which  are  expressed  by  physical  signs,  are  as  follows : 

Changes  of  position,  form,  size,  consistence,  composition,  color 
or  appearance,  and  degree  of  sensitiveness. 

The  means  of  obtaining  physical  signs  are  the  touch — single 
or  bimanual — palpation,  percussion,  speculum,  sound,  probe,  curette, 
exploring-needle,  uterine  dilator,  and  microscope. 

The  art  of  employing  these  means  next  claims  attention. 

EXAMINATION  BY  THE  TOUCH. 

This  examination  is  most  conveniently  practiced  when  the  pa- 
tient is  placed  upon  a  suitable  table.  One  that  is  thirty-three 
inches  high,  forty-three  inches  long,  and  twenty-three  inches  wide. 


8 


DISEASES  OF   WOMEN. 


having  a  projection  on  the  right-hand  corner  upon  which  to  rest 
the  feet,  answers  better  than  any  table  or  chair  that  I  have  ever 
seen. 

The  patient  should  be  placed  upon  the  back,  with  the  pelvis  as 
near  the  end  of  the  tal)le  as  possible,  permitting  the  heels  to  rest 
upon  the  table  also,  while  the  thighs  are  flexed  upon  the  body  and 
the  legs  upon  the  thighs.     A  sheet  held  by  the  edge  in  both  hands 


Fig.  1. — Exaraining  table.    (The  upper  part  of  the  foot-rest  folds  down  as  the  dotted  liu-es 
show,  and  the  support  can  be  pushed  in.) 

is  drawn  over  the  liml)s  from  the  feet  upward,  at  the  same  time 
that  the  skirts  are  pushed  up  out  of  the  way.  This  protects  the 
patient  from  exposure. 

In  this  examination  the  index-finger  of  the  right  hand  is  gener- 
ally employed,  but  both  right  and  left  should  be  educated,  because 
it  is  sometimes  difficult  to  examine  that  side  of  the  pelvis  which 
faces  the  back  of  the  hand  used.  In  critical  cases,  therefore,  it  may 
be  necessary  to  employ  both  hands,  first  one  and  then  the  other,  in 
order  to  complete  the  examination.  In  the  majority  of  cases  it  is 
requisite  to  employ  the  bimanual  method,  as  it  is  termed — that  is, 
while  one  or  two  fingers  are  introduced  into  the  vagina,  the  fingers 
of  the  other  hand  are  placed  upon  the  abdomen  at  the  pelvic  inlet, 
and  by  pressure  the  parts  are  brought  down  to  within  near  reach  of 
the  finger  in  the  vagina.  Fig.  2  illustrates  the  mode  of  making  this 
examination.  This  method  is  quite  satisfactory  in  spare  patients 
with  lax  abdominal  muscles ;  but  when  the  muscles  are  tense,  and 
when  the  walls  of  the  abdomen  contain  a  thick  layer  of  adipose 
tissue,  the  examiner  will  find  great  difficulty  in  practicing  it.     In 


METHODS  OP  OBSERVATION.  9 

such  unfavorable  conditions,  when  the  diagnosis  is  obscure,  much 
will  be  gained  by  using  an  angesthetic.  Examination  of  the  pelvic 
organs  through  the  rectum  is  of  great  value.  In  this  method  the 
touch  is  practiced  in  the  same  way  as  in  that  already  described. 

There  are  other  methods  practiced,  such  as  introducing  two  fin- 
gers into  the  vagina,  the  index  and  the  middle;  and  the  introduction 
of  the  whole  hand  into  the  vagina  or  into  the  rectum.  Simon's 
method  is  to  first  dilate  the  sphincter-ani  muscle,  and  then  pass  the 


Fig.  2. — Bimanual  examination. 


whole  hand  into  the  rectum  as  far  up  as  need  be.  Extraordinary 
advantages  have  been  claimed  for  this  method,  which  brings  all  the 
pelvic  organs  within  the  grasp  of  the  examiner ;  but  it  has  proved 
to  be  dangerous,  and,  owing  to  the  fact  that  pressure  benumbs  the 
hand,  it  is  more  difiicult  than  it  appears  to  be  theoretically.  It 
should  not  be  practiced,  except  in  rare  cases  in  which  it  is  of  vital 
importance  to  make  an  accurate  diagnosis  that  can  not  otherwise  be 
made.     Dilatation  of  the  urethra  sufiicient  to  admit  the  finger  has 


10  DISEASES  OF  WOMEN. 

been  practiced  and  advised  for  the  purpose  of  aiding  in  the  explora- 
tion of  the  pelvic  organs,  but  the  information  gained  in  this  way 
does  not  compensate  for  the  suffering  and  danger  ;  hence  the  prac- 
tice is  rarely  called  for,  and  still  more  rarely  admissible. 

Digital  Touch  by  the  Rectum. — This  method  is  generally  resorted 
to  when  some  obscure,  abnormal  condition  has  been  discovered  by 
the  vaginal  touch.  Much  satisfactory  information  can  be  obtained 
in  this  way,  especially  regarding  the  posterior  wall  of  the  uterus, 
the  ovaries,  and  the  sac  of  Douglas. 

The  bimanual  method  of  practicing  the  rectal  touch  is  the  same 
as  the  vaginal.  Pressure  upon  the  hypogastrium  with  the  external 
hand  gives  the  conjoined  aid,  as  in  examining  by  the  vagina. 

Vesico-Vaginal  Examination. — In  this  method  a  sound  is  passed 
into  the  bladder  while  the  finger  is  in  the  vagina.  By  this  means 
certain  states  of  the  vagina,  urethra,  and  bladder  are  investigated. 

Vesico-Rectal  Examination. — This  is  the  same  as  the  vesico-vaginal 
except  that  the  finger  is  introduced  into  the  rectum.  It  is  the  more 
valuable  of  the  two  in  exploring  all  that  lies  between  the  bladder 
and  rectum. 

Palpation. — Whenever  the  touch  discovers  anything  abnormal^ 
as  a  tumor,  an  enlargement  of  the  uterus,  or  products  of  inflamma- 
tion, additional  information  can  be  obtained  by  abdominal  palpation. 
This  is  accomplished  by  manipulating  the  abdomen  so  as  to  outline 
the  part  in  question,  and  to  test  its  sensitiveness,  mobility,  and 
density.     Both  hands  are  usually  employed  in  this  examination. 

Percussion. — It  is  unnecessary  to  describe  the  manner  of  practicing 
percussion.  Suffice  it  to  say  that  percussion  is  practiced  in  exactly 
the  same  way  in  exploring  the  abdomen  as  it  is  in  exploring  the 
thorax,  the  object  being  to  test  the  density  of  the  abnormal  part  and 
outline  its  relations  to  the  abdominal  organs. 

Palpation  and  Percussion  Conjoined. — This  consists  in  resting  the 
fingers  of  one  hand  at  one  point  on  the  abdominal  walls  and  making 
percussion  at  another  point.  Its  chief  object  is  to  ascertain  if  there 
is  fluid  present ;  this  is  shown  by  fluctuation.  There  are  three  ways 
of  accomplishing  this :  The  flrst  is  to  select  points  on  the  distended 
abdomen  directly  opposite  one  another,  resting  the  fingers  lightly  at 
one  part,  and  percussing  at  the  other.  This  is  known  as  tlie  dia- 
metrical method.  The  second,  the  peripheral  method,  is  to  take 
points  on  a  section  of  the  abdomen  and  manipulate  in  the  same  way. 
The  third  consists  in  resting  the  fingers  at  one  point  and  making 
pressure  at  tlie  other,  to  see  if  the  part  is  wholly  movable  or  partially 
80.  This  differs  from  the  others  essentially  in  substituting  inter- 
rupted pressure  for  percussion. 


METHODS   OF   OBSERVATION. 


11 


Fig.  3. — Sims's  speculum. 


The  Speculum. — This  instrument  is  twofold  in  its  use.  It  is  one 
of  the  most  important  aids  in  the  investigation  of  disease,  and  at 
the  same  time  a 
necessary  instru- 
ment in  treat- 
ment. A  great 
variety  of  spec- 
ula are  used, 
l)ut  two  answer 
all  requirements. 
Sims's  speculum 
and  Cusco's  bi- 
valve, slightly 
modified,  answer 

every  indication.  In  fact,  Sims's  speculum  is  all  that  is  needed,  ex- 
cept when  an  assistant  or  nurse  can  not  be  obtained  to  hold  the  specu- 
lum, then  Cusco's 
may  be  employed 
with  advantage  in 
examining  the  eer 
vix  uteri,  and  for  the 
purpose  of  making 
applications  thereto. 
In  using  Sims's 
speculum  it  is  ne- 
cessary to  have  the 
patient  upon  the 
table  already  de- 
scribed, which  should  be  near  a  window  giving  a  good  light.  Oc- 
casionally it  may  be  necessary  to  examine  a  patient  upon  the  bed, 
but  this  is  difficult,  and  should  not  be  undertaken  until  the  ex- 
aminer has  acquired  by  practice  great  facility  in  the  use  of  the 
speculum,  and  only  then,  when  it  is  impracticable  to  place  the  pa- 
tient upon  the  table.  A  housewife's  cutting  board  placed  beneath 
the  mattress  will  greatly  aid  in  the  examination. 

The  position  of  the  patient  should  be  on  the  left  side,  semi-prone, 
with  the  left  arm  behind  the  back,  the  head  upon  a  low  pillow,  and 
near  the  right-hand  side  of  the  table,  the  limbs  drawn  up,  the  right 
limb  above  and  in  front  of  the  left,  and  the  pelvis  at  the  end  of  the 
table  on  the  left-hand  side.     Fig.  5  illustrates  this  position. 

In  order  to  place  the  patient  in  this  position,  she  should  stand  upon 
an  ottoman  or  low  chair,  with  her  left  side  toward  the  end  of  the 
table.    The  skirts  on  the  left  side  are  then  raised,  and  she  is  directed 


Fig.  4. — Cusco's  bivalve  speculum. 


12 


DISEASES   OF  WOMEN. 


to  sit  down  on  the  table  ;  her  left  hand  is  placed  behind  the  back, 
and  she  is  made  to  lie  down  on  the  left  side,  inclining  forward.    The 


i'lu.  J.     Siiii;'.-;  {jofeition,  seen  from  above.  Fici.  (i. — Nursu  huldiiig  Siiu.s's  .■^lA'cuiuin. 

limbs  are  at  the  same  time  drawn  up  and  placed  in  proper  position. 
The  skirts  are  then  pushed  up  on  the  right  side,  and  at  the  same 


METHODS   OF   OBSERVATION. 


time  a  sheet  is  drawn  over  the  limbs  and  arranged  so  as  to  expose 
the  labia  only. 

The  speculum  is  introduced  by  separating  the  labia  with  the 
fingers  of  the  left  hand,  holding  the  instrument  in  the  right  hand 
by  the  handle  ;  the  point  of  the  blade  is  placed  upon  the  posteri- 
or commissure,  and,  while  backward  pressure  is  made,  the  speculum 
is  passed  into  the  vagina.  Care  should  be  taken  not  to  touch  the 
meatus  urinarius.  The  free  blade  is  then  grasped  with  the  right  hand 
by  the  nurse  or  assistant,  while  with  the  left  she  raises  and  supports 
the  natis  and  labium  on  the  upper  or  right  side.  The  position  of  the 
one  who  holds  the  speculum  should  be  with  the  left  side  toward  the 
patient,  the  fingers  of  the  right  hand  surrounding  the  blade,  while  the 
thumb  rests  in  the  inside  of  the  blade.  The  elbow  should  rest 
against  the  side,  as  a  point  of  purchase  to  give  ability  to  make  steady 
traction.  The  left  arm  should  rest  upon 
the  right  hip  of  the  patient,  while  the 
hand  supports  the  labium  and  natis  to  keep 
them  out  of  the  way  (Fig.  6).  Careful 
training  is  required  to  enable  one  to  hold 
the  speculum  properly.  The  chief  and 
essential  requirement  is  to  maintain  the 
instrument  for  any  desired  length  of  time 
in  the  position  in  which  the  operator  may 
choose  to  place  it.  The  objects  to  be  at- 
tained by  the  use  of  the  speculum  are,  to 
distend  the  vulva  by  making  traction  upon 
the  posterior  commissure,  and  at  the  same 
time  to  draw  the  whole  floor  of  the  pelvis  or  perinseum  backward 

toward  the  sacrum,  away  from  the  pelvic 
organs  above,  which,  from  the  position  of 
the  patient,  gravitate  toward  the  abdomi- 
nal cavity.  By  these  means  the  vagina  is 
distended  by  atmospheric  pressure,  which 
gives  space  for  the  admission  of  light,  and 
room  for  inspection  or  manipulation  in 
operating.  These  facilities  can  be  extend- 
ed by  changing  the  position  of  the  specu- 
lum in  the  following  manner:  The  as- 
sistant who  holds  the  instrument  can,  by 
rotating  the  hand,  cause  the  point  of  the 
blade  in  the  vagina  to  describe  the  arc  of  a  circle  (Fig.  7).  By 
moving  the  hand   forward,  the  blade  is  made  to  point  backward 


Fig.  7. — The  movements  of  the 
speculum.     First  movement. 


Fig.  8.    Second  movement. 


14 


DISEASES   OF   WOMEN. 


Fig.  9. — The  third  movement. 


toward  the  rectum ;  and  by  moving  the  hand  backward,  the  blade 
is  caused  to  point  forward  (Fig.  8) ;  and,  finally,  by  raising  or  lower- 
ing the  hand,  the  speculum  is  made 
to  reflect  the  light  upward  or  down- 
ward to  either  the  upper  orlower  side 
of  the  vagina,  according  to  the  re- 
quirements of  the  examiner  { Fig.  9). 
At  the  same  time  that  all  these 
changes  of  position  are  being  made, 
the  required  traction  upon  the  per- 
inseum  can  be  maintained. 

In  using  the  Cusco  speculum, 
the  position  of  the  patient  is  the 
same  as  for  examination  by  the 
touch.  The  labia  are  separated  with  the  left  hand,  and  the  instru- 
ment introduced  with  the  blades  closed,  the  direction  of  inti-oduction 
being  downward  and  inward.  When  the  speculum  is  in  position  the 
blades  are  separated.  There  is  quite  often  difliculty  in  bringing  the 
cervix  into  view  through  this  instrument.  This  can  usually  be  avoid- 
ed by  getting  the  point  of  the  posterior  blade  well  under  the  cervix 
before  separating  the  blades.  This  speculum  is  principally  used  in 
the  treatment  of  the  simpler  diseases  of  the  cervix  uteri,  when  an  as- 
sistant can  not  be  procured  to  hold  a  Sims's  speculum.  As  a  means 
of  investigation  it  is  quite  limited  in  its  use. 

Hunter's  Depressor. — This  instrument  is  used  to  depress  the 
anterior  vaginal  wall.  It  acts  like  the  anterior  blade  of  a  bivalve 
speculum,  and  is  a  necessary  companion  to  Sims's  speculum.  Of 
all  the  depressors.  Hunter's  I  regard  as  the  best. 


TT.t  1  EM  ANM-COr 


Fig.  10. — Hunter's  depressor. 


THE    UTERINE    SOUND    AND    PROBE. 

There  are  three  kinds  of  sounds :  Simpson's,  which  is  made  of 
hard  metal,  and  maintains  an  unchangeable  shape ;  Sims's,  which  is 
of  soft  metal,  and  can  be  bent  or  molded  to  any  curve ;  and  a  third, 
which  is  elastic  and  bends  on  the  slightest  pressure,  but  by  its  elas- 
ticity regains  its  original  shape.  There  are  two  varieties  of  the  lat- 
ter :  that  made  of  elastic  material  like  whalebone  or  rubber,  and  a 
metallic  one,  rendered  elastic  by  a  spiral  arrangement  in  its  mechan- 
ism, known  as  Jenks's.    Simpson's  sound  is  seldom  used  now,  except 


METHODS   OF   OBSERVATION. 


15 


in  a  modified  form.  It  is  difficult  to  use,  because  its  shape  can  not 
be  adapted  to  different  cases ;  and  it  is  dangerous,  from  the  fact 
that  it  will  not  bend  to  light  pressure. 


Fig.  11. — Sims's  probe. 

Sims's  probe  is  made  of  soft  copper  or  pure  silver,  both  of  which 
metals  have  the  quality  of  being  easily  molded.  It  is  like  the  ordi- 
nary probe  used  in  general  surgery,  only  longer  and  a  little  thicker, 
and  is  provided  with  a  handle  (Fig.  11). 

The  probe  which  is  most  generally  used,  and  the  one  which  I 
prefer  for  ordinary  use,  is  the  same  as  Sims's,  only  thicker.  It  is 
stiff  enough  to  sustain  all  requisite  pressure,  and  yet  can  be  easily 


Fig.  12. — Whalebone  sound. 

molded  to  any  curve.  In  practice  it  is  well  to  be  provided  with 
this  one  as  well  as  that  of  Sims. 

The  elastic  probe  is  the  same  in  form  as  Sims's,  but  is  made  of 
rubber,  gum-elastic,  or  whalebone  (Fig.  12). 

The  sound  of  E.  W.  Jenks  is  hollow  and  spiral  for  a  distance  of 
two  thirds  from  the  pointed  end.  This  spiral  arrangement  gives  it 
flexibility.  It  is  also  graduated  and  provided  with  a  sliding  sheath 
which  is  very  convenient  in  measuring  the  depth  of  the  uterus,  the 


Fig.  13. — Jenks's  sound. 

arrangement  being  such  that  the  examiner  can  run  the  sheath 
toward  or  away  from  him,  the  figures  at  the  end  of  the  sheath  near- 
est the  handle  giving  the  measurement  of  the  distance  from  the 
point  to  the  distal  end  of  the  sheath  (Fig.  13). 

The  sound  or  probe  should  only  be  used  after  the  position  of  the 
uterus  has  been  ascertained  by  a  digital  examination,  and  its  sensi- 
tiveness tested  as  far  as  that  can  be  by  the  touch.  It  is  very  impor- 
tant to  know  the  position  of  the  uterus  and  its  relations  to  the  other 
organs,  in  order  that  the  sound  may  be  curved  to  suit  the  direction 


16  DISEASES   OF   WOMEN. 

of  the  canal  of  the  uterus,  and  to  suggest  the  direction  in  which  the 
instrument  should  be  guided.  There  are  two  ways  of  probing  the 
uterus :  In  the  one,  the  jDatient  is  placed  upon  the  back,  and  the  lin- 
ger of  the  examiner  is  carried  up  to  the  os  uteri ;  the  sound  is 
then  guided  along  the  linger  until  it  enters  the  canal,  when  it  is 
passed  to  the  fundus,  the  handle  being  depressed  to  make  the  sound 
correspond  to  the  direction  of  the  canal  of  the  uterus.  The  other 
way  is  to  expose  the  uterus  with  Sims's  speculum,  and  to  pass  the 
sound  with  the  aid  of  the  eye.  This  latter  method  is  the  easier 
and  safer,  and  gives  at  least  as  much  information  as  the  one  first 
described.  The  vaginal  walls  being  distended  by  the  speculum, 
the  instrument  is  free  to  accommodate  itself  to  the  direction  of  the 
canal  of  the  uterus,  and,  aided  by  sight,  the  os  uteri  can  be  found  at 
once.  Safety  in  using  the  sound  does  not  depend  so  much  upon  the 
touch  which  guides  the  instrument  to  the  uterus  as  upon  the  hand 
that  holds  and  passes  it  into  that  organ.  There  are  few  who  acquire 
the  perfection  of  touch  to  guide  the  sound  into  the  unseen  utenis 
without  using  force,  which,  though  very  slight,  may  cause  mischief. 

In  sounding  or  probing  the  uterus  in  any  way,  force  should  not 
be  used.     This  rule  should  never  be  violated. 

The  Sound  and  Palpation  Combined. — In  this  method  of  examina- 
tion the  sound  is  passed  by  touch,  with  the  patient  upon  the  back, 
and,  while  it  is  in  the  uterus,  it  is  held  with  one  hand ;  the  other 
hand  is  placed  upon  the  abdomen,  and  downward  pressure  made  until 
the  uterus  is  felt.  The  uterus  is  then  moved  by  the  sound,  and  the 
movements  are  detected  by  the  hand  upon  the  abdomen.  The  in- 
formation obtained  in  this  way  will  be  noted  farther  on. 

The  Curette.— This  instrument  is  used  to  explore  the  cavity  of 
the  uterus  in  order  to  detect  any  abnormal  growths  which  may  be 
there,  and  also  to  remove  portions  of  such  growth  for  inspection,  in 
order  to  determine  their  character.  The  instrument  best  adapted  to 
this  purpose  is  made  upon  the  principle  of  the  Recamier  curette.  It 
is  simply  a  scoop  of  small  size  with  a  stem  of  flexible  copper  or  sil- 
ver, the  object  of  this  flexibility  being  to  enable  the  investigator  to 
bend  or  curve  it  to  suit  the  position  of  the  uterine  canal,  and  also 


Fig.  14. — Skene's  curette. 


G  .TIEMANN   &C0. 


that  it  may  bend  before  doing  any  damage  to  the  endometrium  if 
undue  force  is  inadvertently  used  (Fig.  14). 

The  curette  is  introduced  through  a  Sims's  speculum  in  the  same 


METHODS   OF   OBSERVATION, 


17 


manner  as  the  sound,  and  when  once  within  the  cavity  of  the  uterus 
it  is  passed  over  the  surfaces  of  the  endometrium,  and  if  any  pro- 
jections are  detected  a  portion  can  be  scraped  olf  and  removed  for 
inspection.  The  further  use  of  the  curette  will  be  again  described, 
in  connection  with  tlie  treatment  of  diseases  of  the  uterus. 

The  Aspirator. — This  instrument  is  employed  to  investigate  the 
■contents  or  composition  of  tumors  formed  in  the  pelvis.  When  the 
question  arises  whether  the  tumor  present  is  solid  or  fluid,  and  if 
fluid  what  the  character  of  the  fluid  is,  the  use  of  the  aspirator  will 
determine.  The  aspirator  used  in  general  surgery  answers  well ; 
still,  a  hypodermic  syringe,  larger  than  the  usual  size,  and  armed  with 
a  long,  slightly  curved  needle,  thick  enough  at  the  end  nearest  the 
syringe  to  give  it  strength  to  bear  pressure,  is  more  convenient. 

The  method  of  using  the  exploring  aspirator  is  as  follows :  The 
patient  is  placed  upon  the  back,  and  the  point  of  the  needle  is  guided 
to  the  part  to  be  examined,  and  is  then  thrust  into  the  mass  or  tu- 
mor ;  the  piston  is  then  drawn  out,  and  the  fluid,  if  any  be  jDres- 
ent,  is  examined. 

Uterine  Dilators. — "When  it  is  necessary,  as  occasionally  happens, 
to  dilate  the  cervical  canal  in  order  to  explore  the  cavity  of  the 


Fig.  15. — Hanks's  dilator. 


uterus,  resort  must  be  had  to  some  of  the  dilators.     These  are  of 
two  kinds :  The  first  consists  of  graduated  dilators,  which  can  be 


Fig.  16. — Goodell's  dilator. 


j)assed  in  rapid  succession,  such  as  the  dilators  of  Hanks  (Fig.  15), 
and  the  instruments  with  expanding  blades  (Fig.  16).  These  are  in- 
tended to  produce  rapid  divulsion  to  the  required  extent.  The 
other  kind  acts  by  the  swelling  of  the  material  of  wliich  they  are 
made.  Of  these  tents  the  compressed  sponge  (Fig.  17),  sea-tangle, 
and  tupelo  (Fig.  18)  are  in  general  use. 

It  is  seldom  that  tents  are  required  for  purposes  of  examination 

3 


18  DISEASES   OF    WOMEN. 

onlj;  the  dilators  mentioned  answer,  as  a  rule.  They  act  mora 
promptly,  and  are  less  likely  to  cause  after-trouble  if  dilatation  is  not 
carried  to  an  extent  which  is  seldom  necessary  for  purposes  of  ex- 
amination.    Tents  are  to  be  avoided  if  possible,  because  of  the  suffer- 


FiG.  17.— Sponge  tents.  Fig.  18.— Tupelo  tents. 

ing  they  causo,  and  the  danger  of  inflammation  and  blood-poisoning, 
l)Otli  of  wiiich  misfortunes  have  followed  their  use.  They  expand 
slowly,  and  cause  irritation  and  pain,  which  must  be  endured  for 
hours  befoi'e  they  accomplish  their  work.  Acting  thus  like  foreign 
l)odies  and  powerful  irritants,  they  are  not  without  danger.  The 
dilators  act  more  promptly,  and  are  less  likely  to  induce  inflamma- 
tion, and,  although  they  cause  pain  and  irritation,  these  are  of  short 
duration. 

The  Concave  Mirror. — This  is  commonlj'  known  as  the  head-mirror, 
and  is  used  in  the  practice  of  laryngoscopy.  It  is  also  of  much  use 
in  speculum  examinations  when  a  good  light  can  not  he  obtained. 
In  emergencies  oceuri-ing  at  night,  the  mirror  enables  the  surgeon  to 
use  artificial  light  with  perfect  satisfaction.  Placing  a  lamp  by  the 
side  of  the  patient  in  front  of  the  examiner,  the  light  can  be  reflected 
into  the  vagina  so  as  to  expose  the  parts  in  a  very  perfect  way. 
Facility  in  the  use  of  this  mirror  should  be  acquired,  as  it  is  at  times 
indispensable. 

The  Microscope. — A  careful  scrutiny  of  the  minute  structure  of 
pathological  specimens  is  always  necessary  to  complete  diagnosis, 
hence  tlie  microscope  should  be  ])laced  high  in  the  list  of  means  for 
exact  observation  and  investigation.  All  that  need  be  done  in  this 
connection  is  to  remind  the  reader  of  tlie  fact.  A  knowledge  of 
the  microscope  and  its  use  must  be  ol)tained  elsewhere.  The  prog- 
ress in  microscopic  investigation  has  been  go  great  that  many  men 
in  active  practice  have  neither  the  time  nor  the  ability  to  make  their 
own  microsco]iic  investigations.  When  such  is  the  case,  the  duty  of 
the  gynecologist  clearly  is  to  seek  the  aid  of  the  microscopist  that  he 
may  obtain  through  him  the  required  information. 


METHODS  OF  OBSERVATION. 


19 


Anaesthesia. — When  the  parts  to  be  touched  in  examination  are 
very  tender  great  advantage  is  gained  by  the  use  of  cocaine.  A 
two-and-a-half-per-cent  solution  is  safe,  and  can  be  made  efhcient  by 
repeated  or  prolonged  application  to  the  vulva  with  the  McKesson 
and  Robbins  glass  pyrozone  atomizer,  and  to  the  cervix  uteri  with  a 
pipette.  When  there  is  great  tenderness  of  the  pelvic  organs,  and 
the  abdominal  muscles  are  in  a  condition  of  spasm,  which  render 
the  examination  wholly  impossible  or  sufficiently  unsatisfactory  to 
leave  a  doubt  in  the  mind,  then  ether  should  be  given  to  the  extent 


Fig.  18a. — Ether-inhaler.  Its  principle  is  the  same  as  that  of  the  nitrous-oxide  appara- 
tus. The  reservoir,  b,  in  which  the  ether  is  vaporized,  is  separated  from  the  mouth- 
piece, A,  by  the  long  rubber  tube.  The  valves,  e,  of  the  mouth-piece  permit  the 
expired  air  to  escape  without  coming  in  contact  with  the  ether-vapor.  The  valve,  d, 
enables  the  ansesthetizer  to  administer  pure  air  or  pure  ether,  or  any  proportion  of 
air  and  ether,  f  is  the  rubber  tube  and  stop-cock  by  means  of  which  the  mouth- 
piece is  blown  up.  c  is  a  funnel  through  which  the  ether  is  passed,  a  is  the  joint 
uniting  tube  and  inhaler.  The  advantages  of  the  apparatus  are  that  the  ether-vapor 
is  warmed,  that  reinspiration  of  expired  air  is  avoided,  and  that  the  ether  may  be 
diluted  with  air  to  maintain  the  required  antesthcsia.  The  stage  of  violent  excite- 
ment caused  by  partial  suffocation  is  avoided,  and  prolonged  anassthesia  can  be 
maintained  without  the  slightest  imperfection  of  aeration  of  the  blood. 

of  complete  anaesthesia.  The  relaxation  which  this  affords  simpli- 
fies all  investigations  in  a  very  marked  degree.  In  the  investiga- 
tion of  the  pelvic  organs  of  insane  women  and  in  virgins  who  cer- 
tainly require  examination  yet  can  not  submit,  the  nitrous-oxide  gas 
is  of  great  value.  It  acts  quickly  and  pleasantly,  and  has  none  of 
the  effects  during  or  after  its  administration  which  are  so  distressing 
to  those  of  sound  mind  and  horrifying  to  the  insane. 

The  mode  of  administering  it  is  with  the  apparatus  used  by  den- 
tal surgeons,  to  whom  we  are  indebted  for  perfecting  the  apparatus 
for  giving  this  anaesthetic.     The  gas  is  condensed  in  a  strong  cylin- 


20  DISEASES  OF  WOMEN. 

der  which  hold8  one  hundred  gallons.  By  a  valve  arrangement  it 
is  permitted  to  escape  into  a  rubber  bag,  from  which  it  is  inhaled. 
The  inhaler  is  an  ingenious  arrangement  by  which  the  act  of  inspi- 
ration opens  a  valve  that  permits  the  gas  to  be  drawn  from  the 
bag,  while  the  act  of  expiration  closes  the  valve  in  the  supply-tube, 
and  opens  another  valve  for  the  escape  of  the  impure  air.  There  is 
still  another  valve  under  the  control  of  the  operator,  which  admits 
air  with  the  gas,  so  that  when  the  patient  is  fully  anaesthetized  the 
gas  can  be  diluted  with  air  in  sufficient  quantity  to  keep  up  the 
anaesthesia.  The  cylinder  of  condensed  gas  and  the  inhaler  are  put 
up  in  a  case  convenient  to  carry.  I  have  long  employed  a  modifi- 
cation of  this  apparatus  for  ether  inhalation  and  I  find  it  superior 
to  the  inhalers  in  general  use.  Fig.  18a  and  the  accompanying  de- 
scription shows  its  mechanism  and  mode  of  acting. 

To  be  able  to  recognize  the  normal  and  pathological  conditions 
which  are  revealed  by  the  means  described  requires  much  practice. 
It  greatly  aids  in  obtaining  that  practice — in  fact,  it  is  quite  neces- 
sary— to  keep  clearly  in  mind  what  to  look  for.  In  order  to  facili- 
tate the  memorizing  of  the  objects  to  be  investigated,  I  have  ar- 
ranged the  signs  under  each  of  the  various  means  of  obtaining  them 
as  follows : 

Vaginal  Touch. — Position,  size,  shape,  and  density  of  the  uterus. 

Size  and  shape  of  the  os  externum. 

Presence  or  absence  of  discharge  from  cervix. 

Condition  of  vaginal  walls,  perineal  body,  and  recto-uterine  space. 

State  of  the  rectum  and  lower  portion  of  sac  of  Douglas. 

Position  of  the  bladder  and  urethra  as  indicated  through  the  an- 
terior vaginal  wall. 

Presence  or  absence  of  fixation  of  pelvic  organs ;  swelling  or 
tumors  in  the  sac  of  Douglas  or  broad  ligaments. 

Tenderness  at  any  part. 

Bimanual  Touch. — Size,  form,  and  position  of  the  body  of  the 
uterus. 

Tenderness  and  mobility  of  the  uterus  and  other  organs  and 
tissues. 

Position  and  state  of  the  Fallopian  tubes  and  ovaries. 

Condition  of  the  bladder. 

Presence  of  neoplasms  and  their  relation  to  the  pelvic  organs. 

Products  of  inflammation,  their  location  and  character. 

Kectal  Touch. — Condition  of  the  rectum,  posterior  surface  of  the 
uterus,  broad  ligaments,  Fallopian  tubes  and  ovaries,  and  utero- 
sacral  liiraments. 


METHODS  OF  OBSERVATION.  21 

Vesico-rectal  Touch. — Absence  of  the  uterus  from  its  normal 
position  in  inversion  of  the  uterus,  entire  absence  of  the  uterus  ; 
aid  to  diagnosis  in  women  who  are  too  fat  to  permit  the  bimanual 
examination. 

Vesico-vaginal  Touch. — Changes  in  the  position  of  the  bladder 
and  urethra.     Results  of  disease  in  the  vesico-vaginal  septum. 

Palpation. — Form,  size,  and  density  of  tumors  or  products  of  in- 
flammation felt  through  the  abdominal  walls. 

Percussion. — Density  of  morbid  parts. 

Normal  resonance. 

Palpation  and  Percussion  Conjoined. — Fluctuation,  density,  or 
elasticity  of  morbid  parts. 

Speculum. — Appearance  of  mucous  membrane  of  cervix  uteri 
and  vagina. 

Signs  of  inflammation  of  mucous  membrane. 

Relations  of  the  cervix  to  the  vagina. 

Form  of  os  externum. 

Character  of  secretions. 

Signs  of  injury  to  the  cervix  and  vagina. 

Nature  of  new  growths  suggested  by  their  appearance. 

Sound  and  Probe. — Direction  of  the  canal  of  the  cervix  and  cav- 
ity of  the  body  of  the  uterus,  in  relation  to  their  normal  position  in 
the  pelvis. 

Relation  of  the  canal  of  the  cervix  and  cavity  of  the  body  to 
each  other. 

Straight,  deflected,  or  tortuous  state  of  the  cavity  of  the  uterus. 

Long  and  transverse  diameters  of  the  cavity  of  the  uterus. 

Caliber  of  the  cervical  canal,  os  externum,  and  os  internum. 

Degree  of  sensitiveness  or  roughening  of  the  different  portions 
of  the  cavity  of  the  uterus. 

Sound  and  Palpation  Combined. — Displaced  uterus  may  be  raised 
up  to  meet  the  touch  of  the  hand  upon  the  abdomen  for  examination. 

Mobility  of  the  uterus  with  or  without  moving  abnormal  growths 
in  the  pelvis  or  lower  portion  of  the  abdomen. 

Curette.— Presence  or  absence  of  growths  or  tumors  in  the 
uterus. 

Removal  of  portions  of  growths  from  the  cavity  of  the  uterus 
for  inspection. 

Aspiration. — Abstraction  of  fluid  (encysted  or  otherwise)  for  in- 
spection. 

Dilators,  tents,  anaesthetics  and  head-mirror  as  aids  with  other 
means  of  exploration. 


CHAPTER  II. 


DEVELOPMENT  OF  THE  FALLOPIAN  TUBES.  UTERUS,  AND  VAGINA. 


The  Fallopian  tubes,  uterus,  and  vagina  are  developed  from  two 
primary  elements  known  as  Miiller's  filaments.  These  iilaments 
when  first  visible  in  the  embryo  are  solid,  and  are  situated  on  either 
side  of  the  vertebral  column,  a  little  in  front  of  and  on  the  inner  side 
of  two  other  primary  elements,  the  AVolffian  bodies.  The  changes 
which  take  place  in  Miiller's  filaments  durhig  the  evolutions  of  de- 
velopment are  as  follows :  From  solid  fibers,  slightly  enlarged  and 
club-shaped  at  their  upper  ends,  cavities  are  formed,  and  these  be- 
come canals.  Their  lower  ends  approximate  and  coalesce,  from 
below  upward,  less  than  half  their  length.  This  cliange,  which 
takes  place  between  the  ends  of  the  sixth  and  eighth   weeks  of 

foetal  life, 
sented    in 
and     20. 
stage     of 

ment,  Miiller's  ducts 
are  separated  by  a 
septum  fonned  from 
their  coalescent  walls, 
so  that  the  united 
portion  shows  a  right 
and  left  cavity. 
These  two  cavities 
are  soon  converted 
into  one,  the  septum 
disappearing  from 
below  upward  throughout  the  whole  of  the  united  portion  of  the 
ducts.  The  lower  single  canal  thus  formed  is  the  rudimentary  vagina 
and  uterus,  while  the  two  upper  ends  of  Miiller's  ducts  form  the 
Fallopian  tubes  (Fig.  21).     From  this  time  to  the  fifth  month  there 


IS  repre- 
Figs.  19 
At  this 
develop- 


FiG.  19. — Muller's 
ducts. 


Fig.  20.- 


-Coalescence  of 
ducts. 


Fio.  21. — Disappearance  of 
septum. 


Fig.    22.  —  Appearance   of 
fundus  and  cervi.x. 


DEVELOPMENT  OF  THE  FALLOPIAN  TUBES,  ETC. 


28 


is  an  increase  of  tissue,  especially  in  the  upper  portion  of  the  canal, 
which  renders  the  distinction  between  the  vagina  and  uterus  appar- 
ent. The  upper  ends  of  Miiller's  ducts  exj)and  and  become  slightly 
fimbriated  at  their  extremities.  The  upper  portion  of  the  uterus  at 
this  time  is  bifurcated  and  forms  the  two  horns  between  which  the 
fundus  is  subsequently  developed.  Fig.  22  shows  the  oi-gans  at  this 
stage  of  development.  In  the  sixth  and  seventh  months  the  utenis 
increases  in  size,  especially  in  the  cervical  portion,  wliich  at  this 
stage  is  much  larger  than  the  body.  There  is  also  an  increase  of 
tissue  between  the  horns  of  the  uterus  which  renders  their  diverir- 
ence  less  marked.  The  rugose  arrangement  (palma  plicata)  of  the 
rudimentary  mucous  membrane  of  the  cavity  of  tlie  uterus  extends 
very  nearly  to  the  fundus,  its  folds  running  outward  to  the  uterine 
oi-ilices  of  the  Fallopian  tubes.  Ele- 
vations appear  in  rows  upon  the  mu- 
cous membrane  of  the  vagina  which 
are  the  rudiments  from  which  the 
transverse  folds  are  subsequently  de- 
veloped. During  the  eighth  and  ninth 
months  the  thickness  of  the  walls  of 
the  body  of  the  uterus  increases,  the 
fundus  becomes  more  prominent  and 
rounded,  but  u]3  to  the  time  of  birth 
the  cervix  is  larger  than  the  body  of 
the  uterus.  At  the  time  of  birth  the 
primary  development  of  the  uterus  is  complete,  and  it  changes  veiy 
little  in  form  from  that  time  until  the  period  of  pubei'ty.     The  size 

and  appearance  of  the  infantile  uterus  are 
shown  in  Fig.  23.  The  cavity  of  the  uter- 
us and  the  arrangement  of  its  mucous 
membrane  are  represented  by  Fig.  24. 
Fig.  25  gives  a  side-view  of  tiie  uterus 
and  vagina,  and  shows  their  relations  to 
each  other.  At  this  time  the  cervix  pro- 
jects but  little  into  the  vagina. 

From  the  time  of  birth,  when  primary 
development  is  complete,  up  to  the  period 
of  puberty,  the  uterus  undergoes  very  lit- 
tle change  exce^^t  during  the  second  den- 
tition. At  that  time  the  body  increases  in 
size,  becoming  more  nearly  equal  to  the 
cervix.      The    palma   plicata    disappears 


Fig.  23.— Infan- 
tile uterus. 


Fig.  24.  —  Palma 
plicata  extend- 
ing nearly  to 
fundus. 


Fig.    25. — Infantile   uterus,  an- 
tero-posterior  section,  scant 


mvajrination. 


24 


DISEASES  OF  WOMEN. 


from  the  body  of  the  uterus,  excepting  one  longitudinal  fold.  The 
uterus  gradually  descends  into  the  pelvic  cavity  and  the  cervix  is. 
projected  down  into  the  vagina  a  little  farther.  From  this  time  na 
changes  occur  worthy  of  notice  until  puberty,  when  secondary  de- 
velopment takes  place. 

Secondary  development  consists  in  a  general  increase  in  the  size 
of  the  uterus,  especially  in  the  body  and  fundus,  which  become  much 
larger  than  the  cervix.  The  length  of  the  uterus  is  increased.  The 
walls  become  thicker  and  firmer.  The  last  trace  of  the  palma  pli- 
cata  disappears  from  the  mucous  membrane  of  the  cavity  of  the 
l)ody,  and  the  mucous  membrane  becomes  thicker  by  the  formation 
of  its  glandular  tissues.  In  this  way  the  uterus  attains  the  shape 
and  size  of  maturity.  Together  with  the  changes  in  size  and  form 
comes  a  change  of  position.  The  uterus  descends  into  the  pelvis  and 
complete  invagination  of  the  cervix  occurs. 

Fig.  26  shows  the  general  appearance  of  the  mature  uterus  in 
outline,  and  Figs.  27  and  28  represent  the  relations  in  which  the 


Fio.  26.  Fig.  27.  Fig.  28. 

Figs.  26-28. — Virgin  uterus  (Sappey)  :  26,  anterior  view;  27,  median  section;  28,  trans- 
verse section.  26.  1,  body;  2,  2,  angles;  3,  cervix;  4,  site  of  the  os  internum;  6, 
vaginal  portion  of  the  cervix;  6,  external  os.  27.  1,  1,  anterior  surface;  2,  vesico- 
uterine cul-di-nac  ;  3,  3,  posterior  surface ;  6,  isthmus ;  7,  cavity  of  body ;  8,  cavity 
of  the  cervix;  9,  os  internum;  10,  anterior  lip  of  os  oxternuni ;  11,  posterior  lip. 
28.  1,  cavity  of  body;  4,  4,  cornua ;  5,  os  internum;  6,  cavity  of  cervix;  7,  arbor 
vitue  of  the  cervix  ;  8,  os  externum. 

cervix  and  vagina  stand  to  each  other.  By  comparing  Figs.  23  and 
25,  which  illustrate  the  infantile  uterus,  with  Figs.  26  and  27,  the 
difference  between  the  results  of  primary  and  secondary  develop- 
ment will  be  fully  comprehended. 


DEVELOPMENT  OF  THE  FALLOPIAN  TUBES,  ETC. 


25 


MALFORMATION'S  OF  THE   UTERTJS. 

The  malformations  of  the  uterus  are  naturally  divisible  into  two 
classes  :  those  that  occur  during  embryonic  life,  and  those  that  occur 
at  puberty,  the  period  when  secondary  development  takes  place. 
The  first  class  embraces  the  greatest  variety.  Nearly  all  of  these 
malformations  are  due  to  arrest  of  development  at  different  stages  of 
that  process.    The  malformations  most  frequently  seen  are  the  uterus 


a 

Fig.  29. — Double  uterus  and  vagina  from  a  girl  aged  nineteen  (Eisenmann) :  a,  double  vagi- 
nal orifice  with  double  hymen. 

bipartis,  uterus  duplex,  uterus  unicornis,  uterus  bicornis,  uterus  bi- 
fundalis  unicollis,  and  rudimentary  uterus,  generally  known  as  ab- 
sence of  the  uterus.  A  very  rare  condition  has  been  described  as 
hypertrophy  of  the  uterus,  and  classed  with  the  malformations.  It 
is  really  not  a  malformation,  but  a  complete  development  of   the 


26 


DISEASES  OF   WOMEN. 


uterus  during  infantile  life.    When  the  first  evolution  in  the  process 
of  development — i.  e.,  the  union  or  coalescence  of  Miiller's  ducts — 


Pig.  30. — Uterus  unicornis  from  a  young  child,  posterior  aspect  (Pole) :  b,  right  Fallopian 
tube ;  c,  left  Jfallopiau  tube    exceptionally  present ;  d  d,  ovaries  ;  e,  bladder  (Courty). 

is  arrested,  and  each  duct  grows  by  itself,  the  result  is  the  uterus 
bipartis. 

The  uterus  duplex  is  formed  by  the  coalescence  of  the  ducts, 
with  arrest  of  absorption  of  the  central  wall.  The  development 
goes  on,  so  that  in  time  the  whole  organ  is  larger  than  the  normal 
uterus,  but  it  is  divided  into  two  by  the  central  wall  (Fig.  33). 
Uterus  unicornis  is  produced  by  a  complete  arrest  of  development 
of  one  of  the  ducts  at  the  part  which  should  form  one  half  of  the 
body  and  fundus  of  the  uterus  (Fig.  30).  The  uterus  bicornis  occurs 
as  the  result  of  non-union  of  that  part  of  the  ducts  which  forms  the 


Tuba 


Fransen 


Fio.  31. — Uterus  bicornis  unicoUis  (Winckel). 

body  and  fundus  (Fig.  31).  The  uterus  bif  undalis  unicollis  is  formed 
by  the  same  error  of  development  as  that  which  produces  the  uterus 
bicornis  and  double  uterus  with  the  followino;  difference  :  In  the 


DEVELOPMENT   OP   THE   FALLOPIAN  TUBES,    ETC. 


2Y 


uterus  bifundalis  (Fig.  32)  the  liorns,  though  not  united,  are  well 
developed  and  present  outlines  more  nearly  like  the  normal  body 
of  the  uterus,  while  the  part 
which  forms  the  cervix  is 
completely  developed.  Entire 
absence  of  the  uterus  is  per- 
haps unknown,  unless  in  mon- 
strosities in  whom  the  lower 
part  of  the  trunk  is  wanting. 
Rudimentary  uterus  is  seen 
occasionally.  As  most  fre- 
quently found,  it  presents  a 
very  small  cervix  slightly,  if  at 
all,  invaginated,  and  in  place 
of  the  body  of  the  uterus  one  or  two  small  solid  masses  are  found 
from  a  quarter  to  half  an  inch  in  thickness  and  about  the  same  in 
lenffth. 


Fig.  32. — Uterus  bifundalis  unicollis. 


Fig.  3S  — Uterus  duplex  (Cruveilhier).    Left  walls  developed  in  consequence  of  prec:nancy. 

The  effect  of  malformations  as  manifested  during  functional  life 
is  quite  remarkable.  In  some  there  is  not  the  slightest  deviation 
from  health  in  the  function  of  the  sexual  organs.     In  others  the 


28  DISEASES  OF  WOMEN. 

results  are  very  disastrous.  This  practically  gives  two  classes  of 
malformations  according  to  the  effect  they  have  upon  the  health 
and  usefulness  of  the  subject.  In  the  one  class  the  malformation 
does  not  materially  affect  the  function  of  the  uterus,  while  in  the 
other  the  functional  action  is  always  imperfect — sometimes  im- 
possible. The  cases  of  simple  deformity,  in  which  there  are  suffi- 
cient development  and  growth  of  one  or  both  elements  of  the  uterus 
to  make  the  organ  functionally  competent,  have  no  ill  effect  upon 
the  general  usefulness  and  welfare  of  the  individual.  The  follow- 
ing case  will  illustrate  this  : 

Double  Uterus  and  Vagina. — A  married  lady,  thirty-two  years  of 
age,  who  had  borne  three  children  and  nursed  them,  called  upon  me 
for  advice  regarding  a  leucorrhoea  which  had  troubled  her  since  the 
birth  of  her  last  child.  Her  general  health  had  always  been  ex- 
cellent. Upon  making  a  digital  examination,  I  found  the  vagina 
normal  and  also  the  cervix,  excepting  that  one  side  of  the  cervix 
was  closely  united  to  the  vaginal  wall  throughout  its  entire  length. 
On  the  left  side  of  the  vagina  high  up  I  found  a  hard  mass  which 
was  also  noticed  on  making  bimanual  exploration.  The  lirst  im- 
pression was  that  she  had  suffered  from  a  pelvic  cellulitis,  and  that 
the  mass  on  the  left  side  was  the  remains  of  its  products.  This 
idea  was  given  up  at  once  on  finding  that  the  patient  gave 
no  history  of  any  pelvic  inflammation.  I  then  suspected  that 
there  might  be  a  fibroid  in  the  left  side  of  the  uterus,  which, 
by  extending  the  entire  length  of  the  cervix,  had  pushed  the 
vaginal  w^all  before  it.  A  speculum  examination  revealed  a  ca- 
tarrh of  the  cervical  canal.  The  uterus  had  the  usual  appearance 
of  one  that  had  borne  children,  and  the  cervix  was  nonnal  in  shape 
and  position,  except  for  the  peculiar  relations  of  the  cervix  and 
vagina  on  the  left  side,  which  were  noticed  during  the  examination 
with  the  touch.  Just  within  the  labium  minus  on  the  left  side,  a  pe- 
culiar fold  of  the  vaginal  wall  was  noticed  running  •  transversely. 
On  raising  this  fold  with  the  point  of  the  sound  it  was  found  to  be 
a  septum,  and  there  was  also  discovered  another  vagina  to  the  left  of 
it.  Using  a  smaller  Sims's  speculum  to  distend  this  vagina,  I  found 
the  other  cervix  which  had  all  the  characteristics  pertaining  to  a  nul- 
lipara. The  passage  of  a  sound  showed  that  the  canal  of  the  uterus 
on  the  left  side  was  not  quite  so  long  as  the  one  on  the  right.  It 
was  then  clearly  evident  that  the  patient  had  a  double  uterus  and 
vagina,  and  that  the  right  uterus  had  borne  three  children,  while 
the  left  uterus  was  a  virgin  one.  She  was  attended  in  her  confine- 
ments by  three  ditfoi-ent  physicians,  none  of  whom  made  any  refer- 


DEVELOPMENT   OF  THE   FALLOPIAN  TUBES,    ETC. 


29 


ence  to  this  malformation,  and  it  is  fair  to  suppose  that  none  of 
them  discovered  it. 

This  case  is  of  interest  as  showing  the  fact  that  some  of  the  mal- 
formations do  not  in  any  way  affect  the  function  of  the  uterus  nor 
the  general  health  of  the  subject. 

When  there  is  malformation,  and  the  growth  of  the  uterus  falls 
so  far  sliort  of  the  normal  type  that  functional  activity  is  impos- 
sible, the  results  are  often  very  unfortunate.  The  nature  of  this 
class  of  cases  bears  such  close  resemblance  to  those  in  which  there 
is  arrest  of  secondary  development  at  puberty,  that  they  may  be  con- 
sidered together  in  the  following  chapter. 

A  Unique  Case  of  Double  Uterus.  —In  this  case  I  found  a  large 
uterus  with  a  well-formed  cervix,  and  directly  in  front  of  it  a  very 
much   smaller   uterus, 
the    cervix    of   which 
was    but    slightly   in- 
vaginated  (Fig.  34). 

On  my  first  exami- 
nation I  made  a  diag- 
nosis of  uterine  fibro- 
ma. I  thought  that  I 
could  outline  the  tumor 
projecting  from  the 
uterine  wall  toward  the 
bladder.  Subsequently 
I  noticed  a  free  dis- 
charge of  uterine  leu- 
corrhoea  issuing  from 
a  slight  elevation  on 
the  vaginal  wall  in  the 
median  line,  about  an 
inch  from  the  os  ex- 
ternum of  the  larger 
uterus.      I    passed    a 

sound  througli  the  small  opening  in  the  wall  of  the  vagina,  and  found 
that  it  entered  about  an  inch  and  three  quarters,  demonstrating  that 
the  supposed  fibroid  was  a  small  uterus. 

I  account  for  this  strange  malformation  on  the  theory  that,  during 
development  and  after  coalescence  of  Miiller's  ducts,  these  rudiments 
made  half  a  revolution,  thus  bringing  one  in  front  of  the  other. 


Fig.  34. — Double  uterus. 


CHAPTEK   III. 

MENSTRUATION    AND    ITS    DERANGEMENTS,    AND    CHLOROSIS. 

Menstruation  is  the  function  of  tlie  uterus  that  especially  claims 
the  attention  of  the  gynecologist,  though  it  is  only  a  subordinate  part 
of  the  great  process  of  reproduction.  Professor  Stevenson,  of  the 
University  of  Aberdeen,  describes  the  physiology  of  menstruation  as 
a  nutritive  and  active  innervation  wave  that  periodically  runs  to  the 
pelvic  organs,  attaining  its  height  at  the  beginning  of  utero-gestation, 
or,  in  the  absence  of  gestation,  at  the  beginning  of  menstruation.  This 
nutritive  material  is  eliminated  when  the  mucous  membrane  of  the 
cavity  of  the  body  of  the  uterus  undergoes  degeneration,  either 
wholly  or  in  part,  and  is  exfoliated  in  a  granular  state.  This  degen- 
eration and  exfoliation,  according  to  some  observers,  involve  the 
whole  membrane  down  to  the  muscular  walls,  while  others  claim 
that  they  affect  only  the  epithelial  layer.  Be  this  as  it  may,  there 
appears  to  be  a  general  agreement  among  the  authorities  of  the 
present  time  that  degeneration  and  exfoliation  occur  to  an  extent 
sufficient  to  expose  the  smaller  blood-vessels  of  the  endometrium, 
and  to  so  weaken  their  walls  that  they  give  way  and  haemorrhage 
follows. 

This  menstrual  flow  is  composed  of  blood  from  the  vessels,  with 
at  least  the  dehris  of  the  degenerated  and  exfoliated  epithelium. 
The  flow,  which  lasts  for  days,  subsides,  the  mucous  membrane  is 
renewed,  and  the  same  high  state  of  anatomical  completeness  and 
functional  capal)ility  is  restored,  when  another  menstruation  takes 
place,  and  so  this  function  is  repeated  over  and  over  again,  except 
when  suspended  during  pregnancy  or  lactation,  until  the  end  of 
functional  activity  at  forty -Ave  years  of  age  or  thereabout. 

During  the  period  of  functional  activity  of  the  sexual  organs, 
from  puberty  to  the  menopause,  menstruation  is  an  evidence  of 
health,  and  is  also  essential  to  health.  It  is  an  index  of  the  state  of 
the  sexual  system  and  also  of  the  general  health  of  mature  women. 

30 


MENSTRUATION   AND   ITS  DERANGEMENTS.  31 

Hence  its  derangements  constitute  most  valuable  evidence  of  the 
presence  of  disease,  while  its  normal  recurrence  is  an  evidence  of 
health.  In  practice  it  is  best  to  study  this  function  by  its  character- 
istics, rather  than  by  theories  regarding  its  cause  or  the  reasons  for 
its  existence.  It  is  on  this  account  necessary  to  comprehend  its  nat- 
ural history  ;  therefore,  I  propose  to  give  here  a  synopsis  of  the  con- 
ditions of  menstruation. 

The  laws  which  govern  this  function  of  menstruation,  as  given  in 
our  text-books,  are  so  varied  by  climate,  personal  peculiarities,  and 
the  conditions  of  life,  that  a  general  average  pertaining  to  these 
laws  is  about  all  that  can  be  obtained,  and  this  can  be  used  to  very 
little  advantage  in  practice.  Fortunately,  there  are  certain  rules 
which  apply  to  menstruation  with  great  uniformity,  and  these  should 
be  clearly  understood.  The  most  important  of  these  are  the  fol- 
lowing : 

1.  Menstruation  should  begin  at  puberty — i.  e.,  when  the  woman 
is  maturely  developed,  no  matter  what  the  age  may  be.  Increase 
of  size  may  take  place  by  growth  after  puberty,  but  all  the  organs 
of  the  body  should  be  completely  developed,  so  far  as  form  and 
structure  are  concerned,  before  the  function  of  menstruation  is 
taken  up. 

2.  It  should  recur  at  regular  intervals  ;  about  every  twenty-eight 
days  is  the  average  time.  A  regular  periodicity  is  normal,  but  the 
duration  of  the  periods  often  differs  in  different  persons. 

3.  The  discharge  should  always  be  fluid  in  consistence  and  san- 
guineous in  color. 

4.  The  flow  should  continue  a  definite  length  of  time,  the  dura- 
tion depending  upon  the  habit  of  each  case ;  at  least  there  should 
not  be  any  great  deviation  from  this  rule. 

5.  The  quantity  should  be  about  the  same  each  time. 

There  should  be  no  deviation  from  the  first  rule.  If  the  menses 
appear  before  development  is  complete,  both  in  the  sexual  organs 
and  the  general  system,  it  is  an  error  which  is  either  the  result  of 
disease  or  of  the  surroundings  of  the  patient,  and  generally  modifier 
unfavorably  her  future  life  unless  it  can  be  corrected.  The  same 
may  be  said  regarding  those  who  fail  to  menstruate  when  the  devel- 
opment and  growth  of  the  body  are  completed.  The  other  rules  re- 
garding the  recurrence,  duration,  quantity,  and  character  of  the  men- 
strual flow,  may  vary  in  different  women,  but  they  should  be  uni- 
form and  regular  in  each  person.  Whatever  the  habit  may  be  that 
is  established  at  puberty  in  a  given  case,  that  habit  should  be  main- 
tained through  life.     Some  w^omen  menstruate  systematically  from 


32  DISEASES  OF  WOMEN. 

puberty  until  after  bearing  a  child,  then  they  take  up  a  different 
order  of  menstruation  in  regard  to  all  or  some  of  the  characteristics 
of  that  function.  That  is  normal,  but  it  is  the  only  well-marked 
chansre  in  habit  which  is  the  same  in  health. 

Obedience  to  these  laws  of  the  menstrual  function  implies  cer- 
tain conditions  that  are  necessary  to  the  fulfillment  of  these  laws. 
These  may  be  briefly  stated  as  follows  : 

1.  Maturity  of  development  of  all  the  organs,  both  of  the  general 
and  sexual  systems,  and  a  fair  degree  of  health  of  all. 

2.  A  sufficient  and  well-regulated  supply  of  normal  blood  to  the 
sexual  organs. 

3.  Normal  structure  and  functional  activity  of  the  nerves  which 
preside  over  the  action  of  the  sexual  organs. 

4.  Conditions  of  life  favorable  to  general  health  and  reproduc- 
tion.    This  includes  food,  climate,  society,  and  occupation. 

Allusion  has  already  been  made  to  absence  of  the  uterus  and 
also  to  its  rudimentary  states  in  which  the  menses  never  appear,  and 
because  of  these  marked  anatomical  defects  and  absence  of  function 
nothing  can  be  done  by  the  gynecologist  in  the  way  of  improve- 
ment. 

There  remain  to  be  considered  cases  in  which  the  conditions  of 
menstruation  are  all  present  but  in  an  imperfect  degree,  so  that  men- 
struation, although  established,  is  performed  imperfectly. 

ILLUSTRATIVE    CASES. 

uterus  Unicornis;   Imperfect  Menstruation  and  the  Results. — A 

woman,  twenty-nine  years  of  age,  of  healthy  parents,  above  the 
average  size,  and  well  formed  generally,  had  enjoyed  excellent 
health  until  she  was  eighteen  years  of  age.  About  that  time  her 
mammary  glands  became  well  developed  and  she  presented  all  the 
outward  characteristics  of  woman  physical  and  psychical.  She  then 
began  to  suffer  at  stated  periods  from  backache,  a  sense  of  fullness 
in  the  pelvis,  and  slight  leucorrhoea.  In  a  day  or  two  after  these 
symptoms  came  on,  and  while  they  continued,  she  became  dull 
and  sleepy,  and  had  a  feeling  of  fullness  in  the  head  and  slight 
headache.  These  attacks  lasted  several  days,  when  they  passed  off 
and  again  returned  about  every  montli.  In  the  interval  her  health 
was  good  and  she  performed  her  duties  as  a  domestic.  Five  months 
after  the  first  time  that  these  symptoms  appeared,  and  while  she  was 
suffering  from  an  attack,  she  had  a  slight  menstrual  flow,  which 
lasted  less  than  twenty-four  hours,  and  apjwared  to  alleviate  her 
suffering.     The  next  month  her  flow  returned  in  the  same  way,  but 


MENSTRUATION  AND  ITS   DERANGEMENTS.  33 

all  her  symptoms  were  increased.  From  this  time  on  her  men- 
strual flow  returned  regularly,  but  did  not  increase  in  duration  or 
quantity.  At  each  recurring  menstrual  period  her  suffering  in- 
creased in  severity  until  she  was  obliged  to  give  up  her  duties  at 
such  times.  On  one  occasion  when  she  was  trying  to  do  her  work 
while  suffering,  she  was  exposed  to  cold  and  was  seized  with  an 
inflammation — j)elvic  peritonitis,  no  doubt — and  was  taken  to  the 
hospital,  where  she  remained  for  three  months.  During  that  time 
she  took  morphine  liberally.  From  this  time  her  suffering  dur- 
ing the  menstrual  period  was  very  great,  sufficiently  so  to  keep 
her  in  bed,  and  to  require  large  doses  of  morphine  to  make  life 
tolerable.  Another  attack  of  pelvic  peritonitis  came,  and  again 
she  was  sent  to  the  hospital  for  treatment.  She  recovered  from 
the  acute  attack,  but  her  suffering  at  her  periods  was  far  greater 
than  ever  before.  Epileptiform  convulsions  came  w^ith  her  pelvic 
pains,  and  were  repeated  frequently  until  the  menstrual  period 
passed  by.  For  several  years  her  time  was  spent  between  her  home 
and  the  hospital,  and  in  occasional  efforts  to  do  the  duties  of  a 
house-servant. 

Condition  when  First  Examined. — Having  obtained  the  above 
history  from  the  patient,  I  observed  that  she  still  had  all  the  evidence 
of  fair  general  health,  except  that,  from  pain  and  the  use  of  mor- 
phine, her  nervous  system  was  decidedly  impaired. 

Physical  Signs. — The  touch  detected  a  very  small  cervix  nteri 
which  projected  into  the  vagina  only  half  an  inch.  The  organs  and 
tissues  were  fixed,  and  on  the  left  side  there  was  an  irregular  mass 
"which  felt  like  the  products  of  a  former  pelvic  peritonitis.  On  the 
right  side  the  parts  were  less  elastic  than  normal,  and,  owing  to 
an  exceedingly  tense  state  of  the  abdominal  muscles,  the  body  of 
the  uterus  could  not  be  felt,  neither  could  the  right  ovary  be  posi- 
tively made  out.  From  the  negative  signs,  however,  I  was  able  to 
satisfy  myself  that  the  right  ovary  was  not  enlarged,  nor  was  the 
body  of  the  uterus  as  large  as  it  ought  to  be.  The  speculum  re- 
vealed nothing  of  value,  but,  in  using  the  sound  through  it,  I  could 
pass  that  instrument  into  the  cavity  of  the  uterus.  The  canal  of 
the  cervix  was  an  inch  in  length,  and  in  its  proper  position  as 
indicated  by  the  sound.  When  the  internal  os  was  reached,  the 
sound  turned  to  the  right  and  passed  in  that  direction  about  an 
inch.  This  led  me  to  suspect  that  the  uterus  was  unicornis.  To 
obtain  further  evidence,  the  speculum  was  removed,  while  the 
sound  was  left  in  the  uterus.  The  patient  was  then  placed  upon 
the  back,  and  by  the  rectal  and  vaginal  touch  combined,  the  horn 
4 


34  DISEASES  OF  WOMEN. 

of  the  uterus  above  the  vagina  was  reached.  While  making  the 
combined  touch,  an  assistant  rocked  the  horn  of  the  uterus  with 
the  sound,  and  I  could  then  outline  it  with  the  fingers.  It  was 
about  an  inch  in  its  transverse,  and  only  a  little  more  in  its  long 
diameter.  The  upper  end,  which  represented  the  fundus,  appeared 
to  be  slightly  pointed  in  place  of  rounded,  as  is  the  fundus  of  the 
normal  uterus. 

Treatment. — There  was  nothing  in  the  case  to  give  the  slightest 
hope  that  she  would  derive  benefit  from  any  general  treatment. 
The  removal  of  the  ovaries  to  stop  the  tendency  to  menstruation  was 
the  only  indication  apparent  to  my  mind,  and,  owing  to  the  old  adhe- 
sions from  the  former  pelvic  peritonitis,  the  dangers  of  that  opera- 
tion were  fully  appreciated.  The  case  was  explained  to  the  patient 
and  the  friends  who  brought  her  for  my  advice,  and  they  were  left 
to  choose  between  the  removal  of  the  ovaries,  or  no  further  care  on 
my  part.  The  patient,  after  thinking  of  the  dangers  and  the  pros- 
pects, became  very  anxious  for  the  operation.  Her  argument  was 
that  she  was  tired  of  life,  and  that  all  her  friends  were  tired  of  car- 
ing for  her,  and,  if  there  was  one  chance  in  a  thousand  of  being  re 
lieved,  she  longed  for  that  chance. 

The  operation  was  performed  with  great  difiiculty,  owing  to  the 
adhesions.  The  right  ovary  was  completely  surrounded  with  inflam- 
matory products,  and  was  found  with  much  trouble.  The  left  ovary 
was  adherent  at  several  points  that  were  easily  broken  up.  There 
was  no  trace  of  the  left  horn  of  the  uterus,  nor  of  the  left  Fallopian 
tube.  The  right  ovary  was  located  within  one  inch  of  the  upper 
end  of  the  right  horn  of  the  uterus,  and  there  was  no  well-defined 
Fallopian  tube  on  that  side. 

Comments. — This  case  certainly  illustrates  fully  the  great  suffer- 
ing that  may  arise  from  this  degree  of  malformation.  The  presence 
of  well-developed  ovaries  which  excite  a  demand  for  menstruation, 
associated  with  a  uterus  incapable  of  performing  that  function,  is 
one  of  the  most  unfortunate  conditions  known  to  the  gynecologist. 
It  is  evident,  also,  that  the  development  of  the  one  horn  of  the 
uterus  sufficient  to  make  a  slight  effort  to  menstruate  only  aggra- 
vates the  difficulty.  This  patient  would  perhaps  have  been  better 
had  the  uterus  been  absent  altogether. 

Incidentally,  I  may  remark  that  the  absence  of  the  tubes  in  this 
case  is  evidence  against  those  who  claim  that  they  have  a  leading 
influence  in  causing  menstruation. 

Rudimentary  Uterus  Bicornis;  Entire  Absence  of  Menstruation. — 
AVhen  first  examined,  this  lady   was  thirty  years  old,  below  the 


MENSTRUATION  AND  ITS  DERANGEMENTS.  35 

average  size,  but  well  formed,  and  presented,  to  outward  appear- 
ances, all  the  characteristics  of  her  sex.  As  a  child  she  was  rather 
small  and  delicate,  but  had  good  health.  At  the  age  of  sixteen 
she  passed  through  all  the  changes  of  form  common  to  puberty, 
but  never  menstruated.  When  questioned  regarding  her  health 
at  that  time,  she  remembered  only  that  slie  occasionally  had  slight 
headache  and  indisposition,  but  wliether  these  symptoms  came  peri- 
odically or  not  she  did  not  know.  At  no  time  was  her  suffering 
sufficient  to  interrupt  her  school  duties.  She  was  married  at 
eighteen,  and,  while  she  was  affectionate  and  devoted  as  a  wife, 
sexually  she  was  perfectly  negative.  Without  being  very  strong 
mentally  or  physically,  she  enjoyed  good  health,  and  only  called 
upon  me  at  the  time  she  did  because  of  some  temporary^  irritation 
of  the  urethra  which  caused  pain  on  urination.  This  gave  me  an 
opportunity  to  examine  her  pelvic  organs.  The  external  organs 
were  normal,  and  the  vagina  also.  The  cervix  uteri  was  not  more 
than  five  eighths  of  an  inch  in  diameter.  The  os  externum  was 
small  but  normal.  In  the  location  of  the  body  of  the  uterus  two 
small,  oblong,  bifurcated  bodies  were  found  continuous  with  the 
cervix.  These  bodies  were  about  a  quarter  of  an  inch  thick  and 
about  an  inch  long,  as  nearly  as  could  be  estimated  by  the  bimanual 
examination.  I  regarded  them  as  the  rudimentary  horns  of  the 
uterus,  which  were  retroverted.  ]^ear  the  upper  ends  of  the  horns 
of  the  uterus,  and  a  little  outside  of  them,  two  other  bodies  were 
found  which  I  presumed  to  be  the  ovaries.  They  were  about  half 
the  size  of  a  fully-developed  ovary  and  of  the  usual  form  of  that 
organ,  except  that  they  were  not  so  flat  from  before  backward,  and 
appeared  to  be  more  dense  than  normal.  It  was  evident  that  the 
development  of  the  ovaries  had  progressed  further  than  that  of  the 
uterus,  because  they  were  relatively  much  larger  than  the  rudiments 
of  the  uterus.  Owing  to  the  fact  that  the  patient  was  of  small  size, 
with  non-resisting  abdominal  muscles  and  the  rudiments  of  the  uterus 
retroverted,  the  examination  was  easy,  so  that  I  feel  some  confidence 
in  giving  the  physical  signs  and  the  diagnosis  based  upon  them, 
believing  that  they  are  correct. 

Comments. — This  case  apparently  shows  that  the  ovaries  were 
sufficiently  developed  to  influence  the  changes  which  occur  at 
puberty,  but  were  so  much  under  size  that  they  were  incapable  of 
the  highest  functional  activity,  while  the  uterus  was  not  only 
arrested  in  its  development,  but  in  its  growth  also ;  hence  men- 
struation, even  in  an  imperfect  way,  was  impossible.  This  case  is 
placed  in  contrast  with  the  preceding  one  to  show  that  when  arrest 


36  DISEASES  OF   WOMEN. 

of  development  and  growth  is  such  as  to  render  functional  action 
entirely  impossible,  a  fair  degree  of  health  may  still  be  maintained  ; 
while,  on  the  other  hand,  if  the  development  and  growth  of  the 
ovaries  are  complete,  and  the  nterus  is  developed  sufficiently  to 
make  an  imperfect  effort  to  menstruate,  the  health  and  usefulness 
of  such  a  one  is  greatly  impaired,  and  a  life  of  suffering  generally 
follows. 

Small  Uterus  from  Arrested  Growth ;  Scanty  Menstruation  improved 
by  Treatment. — The  patient  was  a  young  woman  of  full  size  and 
well  formed,  and  of  a  sanguine,  nervous  temperament,  and  a  re- 
markably good  and  well-cultivated  mind.  She  had  always  enjoyed 
good  health  excepting  when  she  was  fourteen  years  old.  At  that 
time  she  was  "  working  hard  at  school,  and  became  run  down." 
Rest  soon  restored  her,  and  she  began  to  menstruate  at  the  age  of 
fourteen  years  and  six  months.  Her  menses  from  that  time  returned 
regularly,  but  the  flow  was  scanty  and  lasted  only  forty-eight  hours. 
During  the  menstrual  period,  and  for  several  days  after  it,  she  suf- 
fered from  fullness  of  the  head,  restless  nights,  and  a  feeling  of 
discomfort  in  the  pelvis  with  general  mental  and  physical  indispo- 
sition. She  continued  in  this  way  until  she  was  mature,  the  time 
when  she  was  first  examined.  By  the  touch  the  cervix  uteri  was 
found  to  be  rather  small,  but  well  formed  and  in  proper  relations  to 
the  vagina.  Owing  to  the  rigid  state  of  the  abdominal  muscles,  the 
uterus  could  not  be  satisfactorily  outlined  by  the  bimanual  touch. 
Using  the  sound  through  the  speculum,  the  long  diameter  of  the 
uterus  was  proved  to  be  one  and  seven  eighths  inches ;  quite  a  small 
uterus  for  a  woman  of  her  size.  Her  general  health  was  very  good 
indeed,  and  she  would  not  have  sought  immediate  advice  had  it  not 
been  that  she  was  engaged  to  be  married,  and  was  very  anxious  to 
be  relieved  from  the  ill  feelings  which  came  in  connection  with  her 
scanty  menstruation. 

Treatment. — At  her  next  period  she  was  directed  to  take  a  tea- 
spoonful  every  three  hours  of  the  following  mixture  :  Ammon.  mur., 
3ij  ;  aquse  camph.,  ^  ij,  to  begin  as  soon  as  she  felt  that  the  period 
was  approaching,  and  to  continue  until  six  hours  after  the  flow 
stopped.  Xot  being  used  to  medicine,  she  objected  to  it  strongly, 
and  during  her  subsequent  periods  she  took  a  teaspoonful  of  liq. 
ammon.  acetatis  every  three  hours,  commencing  one  day  before  the 
flow  began  and  during  its  continuance.  Immediately  after  the  flow 
ceased,  one  or  more  fine  punctures  were  made  near  the  external  os, 
which  produced  considerable  bleeding.  This  was  done  to  relieve, 
as  far  as  possible,  the  congestion  M'hich  lingered  because  it  was  not 


MENSTRUATION  AND  ITS  DERANGEMENTS.  37 

relieved  by  the  menstrual  flow.  This  was  practiced  after  three  pe- 
riods. At  intervals  of  six  days  during  the  entire  menstrual  flow  the 
canal  of  the  cervix,  including  the  internal  os,  was  gently  dilated 
with  graduated  sounds.  This  was  done  in  the  hope  that  it  would 
stimulate  the  nutrition  of  the  uterus. 

After  the  third  month  of  treatment  it  was  found  that  the  men- 
strual flow  had  increased  in  quantity  and  continued  for  one  day 
longer.  A  stem-pessary  was  then  introduced,  but  it  caused  more 
irritation  than  was  safe ;  so,  after  it  had  been  worn  for  three  days, 
it  was  removed,  and  not  used  again. 

From  this  time  onward  the  treatment  was  limited  to  a  mild  con- 
stant electric  current.  One  electrode  was  passed  into  the  uterus,  the 
other  applied  alternately  over  the  sacrum  and  supra-pubic  region. 
This  was  repeated  every  six  days  in  the  interval  between  the  monthly 
periods.  She  continued  to  take  the  solution  of  acetate  of  ammonia 
at  each  period,  but  with  what  benefit  is  not  known.  At  the  end  of 
eight  months  the  uterus  measured  two  inches  and  one  eighth  in  its 
long  diameter,  and  she  menstruated  between  four  and  five  days  at 
each  time,  the  flow  being  much  more  free  and  her  unpleasant  symp- 
toms having  all  disappeared.  She  married  then,  and  I  lost  sight  of 
her  for  seven  months,  when  she  called  to  consult  me  regarding 
amenorrhosa,  which  had  existed  for  two  months  and  was  due  to 
pregnancy.  I  heard  that  subsequently  she  was  confined,  and  was 
in  quite  good  health. 

Undersized  Uterus  from  Arrested  Growth ;  Scanty  Menstruation ; 
Sterility;  Incurable. — This  woman  was  thirty  years  old  when  this 
history  was  obtained.  She  was  of  medium  size,  and  had  enjoyed  fair 
health  most  of  her  life.  During  her  girlhood  she  had  to  w^ork  very 
hard  in  a  store,  and  often  sufliered  at  that  time  from  fatigue.  She 
developed  slowly,  and  did  not  menstruate  until  seventeen  years  of 
age.  During  the  first  four  years  after  puberty  the  menses  lasted 
only  two  days  and  the  flow  was  scanty.  At  twenty-two  she  was 
married,  and  placed  in  easier  and  more  comfortable  circumstances, 
and  for  about  one  year  the  menstrual  flow  lasted  from  two  and  a 
half  to  three  days  at  each  time.  She  then  missed  one  period,  and 
then  the  menses  returned  more  freely  than  ever  before,  which  made 
her  believe  she  had  had  a  miscarriage  ;  but  of  this  there  was  no 
proof.  When  she  had  been  married  two  years  she  began  to  have 
pain  of  a  dull,  aching  character  in  the  region  of  the  uterus  during 
her  menses.  This  pain  became  more  marked  as  time  advanced,  and 
gradually  the  pain  extended  to  the  ovaries.  These  pains  were  never 
acute,   and   passed    away  entirely  after    menstruation    ceased.     At 


38  DISEASES  OF  WOMEN. 

twenty-nine  years  of  age  she  had  sickness  in  her  family  and  was 
overtaxed  tliereby,  and  her  menses  stopped  for  five  months,  but 
again  returned.  In  tlie  absence  of  the  menses  she  had  leucorrhoea, 
but  not  before  nor  since. 

Examination  by  the  touch  showed  the  uterus  to  be  relatively 
long  and  narrow ;  the  body  was  not  much  larger  than  the  cervix. 
The  long  diameter  as  measured -with  the  sound  was  two  inches. 
There  was  slight  tenderness  on  pressure  over  the  ovaries.  All  the 
pelvic  organs  were  in  normal  position.  Her  general  health  was 
about  as  good  as  it  ever  had  been. 

Treatment. — Sodium  bromide,  gr.  xxx,  was  given  three  times  a 
day  in  Yicliy  water  before  meals  during  the  menstrual  period.  This 
relieved  the  uterine  and  ovarian  pain  very  much.  Between  the 
periods  the  hot-water  douche  was  used  until  all  pain  had  been  relieved. 
The  subseipieiit  treatment  was  about  the  same  as  in  the  case  last 
related,  with  the  addition  of  more  extensive  dilatation  of  the  cervical 
canal,  and  she  also  wore  the  intra-uterine  stem-pessary  for  six  weeks. 
!Slie  took  internally  phosphates,  iron,  and  strychnia  in  various  forms, 
and  for  several  months. 

At  the  end  of  seven  months  she  was  free  from  all  pain  during 
menstruation,  but  the  flow  was  no  freer,  nor  did  it  last  any  longer. 
The  uterus  had  not  in  the  least  increased  in  size.  She  was  dis- 
missed unimproved,  so  far  as  the  growth  of  the  uterus  was  con- 
cerned. 

Comments. — This  and  the  preceding  case  are  placed  together  to 
show  the  results  of  treatment.  They  demonstrate  that  the  prospects 
of  success  in  increasing  the  growth  of  the  uterus  depend  very  largely 
upon  the  age  of  the  patient.  The  earlier  in  life  that  the  treatment 
is  begun,  the  more  likelihood  is  tliere  of  success. 

Undersized  Uterus,  its  Growth  apparently  being  arrested  by  Pre- 
mature Sexual  Nervous  Excitation;  Irregular  and  Painful  Menstrua- 
tion; all  the  Symptoms  increased  by  Local  Treatment. — This  was  a 
single  wonuui,  twenty-two  years  old,  the  daughter  of  wealthy  and 
educated  parents.  She  was  tall,  spare,  and  of  nervous  tempera- 
ment. Before  puberty  she  acquired  the  habit  of  self-abuse  while 
at  school.  While  her  general  system  was  not  developed,  and  while 
weak,  irritable,  dyspeptic,  and  subject  to  severe  headaches  she  be- 
gan to  give  evidences  of  puberty,  and  her  menses  first  appeared  at 
twelve  years  of  age.  From  this  time,  up  to  the  time  of  taking  this 
history,  she  menstruated  irregularly,  the  average  time  between  the 
periods  being  five  weeks,  but  often  two,  three,  and  on  several  oc- 
casions  five   months   elapsed.      The   flow  was   usually   normal   in 


MENSTRUATION  AND  ITS  DERANGEMENTS.  39 

quantity,  character,  and  duration,  although  the  latter  was  variable. 
Pain  in  the  back,  pelvis,  and  lower  portion  of  the  abdomen  always 
accompanied  the  menses,  and  was  sufficiently  severe  to  keep  her  in 
bed  during  that  period.  The  severity  of  the  pain  was  presumably 
not  so  great  as  the  patient  described.  Her  extreme  sensitiveness 
inclined  her  to  exaggerate  her  sufferings.  Neither  was  the  chai-acter 
of  the  pain  so  acute  and  localized  as  that  which  occurs  in  flexion  of 
the  uterus.  Her  general  health  was  poor,  slight  mental  or  physical 
exercise  fatigued  her,  and  if  she  persisted  she  became  so  tired  that 
she  could  not  rest.  Her  sleep  was  disturbed  by  dreams  that  were 
not  all  dreams,  and  in  the  morning  she  felt  quite  exhausted.  Be- 
fore I  saw  her  she  had  been  treated  locally  and  generally  by 
several  physicians,  some  of  high  standing  in  the  profession,  and 
others  of  questionable  repute,  and  was  invariably  worse  after  being 
treated. 

An  examination  by  touch  revealed  a  small  uterus  slightly  retro- 
verted,  though  that  malposition  was,  I  believe,  temporary.  The 
length  of  the  uterine  cavity  measured  with  the  sound  was  a  fraction 
less  than  two  inches.  With  the  exception  of  extreme  sensitiveness 
of  the  pelvic  organs  generally,  there  was  no  other  abnormality 
found. 

Local  treatment  was  tried  for  a  short  time,  but  it  was  found 
to  be  injurious.  She  was  then  given  systematic  occupation  under 
the  direction  of  a  skilled  attendant.  Massage  and  careful  dieting 
were  also  directed.  Her  days  were  fully  occupied  with  short  alter- 
nating periods  of  mental  and  physical  exercise  and  rest.  Every 
a,fternoon  she  took  thirty  grains  of  bromide  of  sodium,  and  during 
her  menstrual  periods  thirty  grains  three  times  a  day  with  eight 
drops  of  tincture  of  cannabis  Indica.  Laxatives  were  given  to  regu- 
late the  bowels,  and  tonics  occasionally  when  specially  required. 
It  should  be  mentioned  that  she  gave  up  her  evil  habit  as  soon 
as  she  was  made  to  understand  its  ill  effects.  Under  this  general 
plan  of  treatment  she  improved  in  every  respect.  She  still  suf- 
fers at  her  monthly  periods,  and  the  menstrual  function  is  still 
irregular. 

Comments. — This  case  is  given  as  a  representative  of  that  class  of 
cases  of  delayed  or  arrested  growth  of  the  uterus  and  the  functional 
imperfection  which  is  sure  to  follow,  the  primary  cause  of  all  being 
the  premature  excitation  of  the  sexual  organs.  A  sufficient  number 
of  these  cases  has  been  seen  and  studied  to  warrant  the  statement 
that  when  the  habit  of  self-abuse  is  begun  before  puberty  it  often 
arrests  the  development  or  growth,  or  both,  of  the  uterus,  and  the 


40  DISEASES  OF  WOMEN. 

consequences  are  far  more  disastrous  than  the  same  practice  when 
begun  after  puberty  and  completed  growth. 

Chlorosis. — Closely  associated  witli  this  subject  is  chlorosis,  a 
condition  involving  menstrual  derangements  due  to  the  same  de- 
fect of  the  uterus,  being  associated  with  lesions  of  the  general 
system.  Chlorosis  is  a  condition  which  has  usually  been  considered 
as  a  disease  ])er  se^  but  it  appears  to  me  to  be  rather  a  peculiar 
character  of  organization  presenting  invariably  certain  character- 
istics of  structure  which  are  unfavorable  to  high  functional  activity, 
and  which  predispose  to  certain  forms  of  disease.  Some  authori- 
ties, French  mostly,  believe  that  chlorosis  is  a  disease  of  the  organic 
nervous  system  which  appears  at  puberty  and  presents  certain 
changes  of  nutrition,  especially  in  the  character  of  the  blood. 
There  is  certainly  some  reason  for  this  view  of  the  subject.  The 
functions  of  the  body  which  are  under  the  direct  control  of  the 
organic  nerve-centers  are  perverted  apparently  by  some  obscure 
derangement  of  organic  innervation,  but  this  appears  to  come  from 
some  imperfection  of  the  nervous  system,  perhaps  mal-develop- 
ment,  rather  than  from  some  well-defined  disease.  The  German 
pathologists  hold  that  in  chlorosis  there  is  an  arrest  of  growth  of 
the  circulatory  and  genital  systems ;  the  heart  and  blood-vessels  be- 
ing undersized  and  the  sexual  organs  also.  This  certainly  cor- 
responds to  the  facts  as  observed  clinically,  and  if  to  this  be  added 
that  peculiar  condition  of  the  organic  nervous  system,  which  is  un- 
defined but  probably  structural,  a  type  of  organization  results 
which  presents  all  the  tangible  characteristics  of  chlorosis.  This  is 
the  conception  which  I  have  accepted  regarding  chlorosis,  which 
may  be  defined  as  an  organization  in  which  the  circulatory  and  the 
genital  systems  are  below  the  normal  type  in  point  of  development 
and  growth,  and  in  which  there  is  a  state  of  the  organic  nervous 
system  which  is  also  below  the  normal  and  incapable  of  exercising 
the  highest  functional  activity.  These  constitutional  conditions 
combine  the  features  of  a  peculiar  temperament  and  a  diathesis ; 
the  temperament  being  so  marked  as  to  show  a  tendency  to  disease 
or  diathesis.  It  would  siiqplify  the  subject  if  the  term  chlorotic 
temperament  Avere  used  to  express  this  constitutional  condition. 
Viewing  the  subject  from  this  standpoint,  it  is  easy  to  understand 
that  such  an  organization,  while  it  might  act  under  the  most  favor- 
able circumstances  of  life,  would  be  incapable  of  sustaining  the 
more  complex  functional  activities  of  a  mature  and  fully  occupied 
life.  It  is  easy  to  see,  also,  that  a  chlorotic  subject,  when  called 
upon  to  take  up  the  functions  of  reproduction,  when  thus  ill-quali- 


MENSTRUATION  AND   ITS  DERANGEMENTS.  41 

fied  to  do  so  by  reason  of  anatomical  defects,  would  naturally  tend 
to  derangements  of  nutrition  in  the  form  of  impaired  appetite, 
labored  digestion,  and  the  ansemia,  debility,  and  mental  depression 
which  naturally  follow  mal-iiutrition.  So,  also,  would  the  sexual 
system  suffer  because  of  the  undersize  of  the  uterus  and,  pre- 
sumably in  some  cases,  the  ovaries  also,  together  with  the  im- 
perfect Ijlood-supply  which,  sooner  or  later,  comes  from  the  mal- 
nutrition. This  I  believe  to  be  the  true  state  of  the  body  knov/n 
as  chlorosis,  and  that  all  the  phenomena  manifested  by  such  sub- 
jects are  the  outcome  of  their  anatomical  peculiarities.  Whether 
this  be  the  proper  description  of  chlorosis  or  not,  it  is  the  expres- 
sion in  brief  of  the  prominent  features  of  chlorotic  subjects,  and 
agrees  with  the  facts  observed  in  practice.  The  reason,  I  presume, 
for  the  different  opinions  held  has  grown  out  of  the  fact  that  some 
have  accepted  the  mal-nutrition  which  is  so  often  seen  in  the 
chlorotic,  and  the  consequences  thereof,  as  the  disease  itself ;  where- 
as these  derangements  of  the  nutritive  and  sexual  systems  are  the 
outcome  of  the  anatomical  imperfections.  The  chief  object  in  dis- 
cussing the  subject  here  is,  because  chlorotic  women  necessarily 
suffer  from  deranged  and  imperfect  menstruation,  and  they  natu- 
rally fall  into  the  care  of  the  gynecologist,  and  without  some  defi- 
nite idea  of  the  nature  of  this  affection  its  rational  management 
would  not  be  possible. 

From  the  very  nature  of  chlorosis,  it  is  clearly  evident  that  the 
object  of  the  therapeutist  should  be  to  aid  in  the  development  and 
growth  of  the  subject  while  young,  in  the  hope  of  overcoming  the 
natural  tendencies  to  these  constitutional  defects.  After  adolescence 
the  most  that  the  physician  can  accomplish  is  to  overcome,  as  far  as 
can  be,  the  mal-nutrition  and  derangements  of  menstruation  which 
arise  from  the  constitutional  imperfections. 

Arrested  Growth  of  the  Uterus,  associated  with  Small  Circulatory- 
Organs  ;  Chlorosis. — This  patient  stated  that  when  a  girl  she  was  of 
medium  size  and  quite  fleshy,  and  was  said  by  her  friends  to  look 
strong  and  healthy,  but  she  was  never  able  to  endure  much  muscu- 
lar exercise.  Her  appetite  and  primary  digestion  had  generally  been 
good,  yet  she  never  required  a  large  quantity  of  food.  Her  face 
was  rather  pale  while  a  girl,  and  remained  so.  She  never  was  in- 
clined to  take  active  exercise,  and,  when  obliged  to  do  so,  respira- 
tion was  labored,  and  she  soon  became  tired. 

At  the  age  of  fifteen  she  began  to  show  the  general  form  of 
womanhood,  but  did  not  menstruate  until  eight  months  later.  From 
that  time  onward  she  menstruated  regularly,  but  the  flow  lasted  only 


42  DISEASES  OF  WOMEN. 

three  dajs,  and  was  not  at  all  free.  On  several  occasions,  when 
obliged  to  exert  herself  sufficiently  to  slightly  lower  her  general 
health,  the  menstrual  flow  was  almost  colorless,  and  lasted  only  two 
days.  At  twenty-one  she  was  married.  Her  general  health  re- 
mained as  before,  and  she  proved  to  be  sterile.  I  saw  her  when 
she  was  twenty-eight  years  of  age,  seven  years  after  being  married. 
She  then  consulted  me  regarding  her  sterility. 

In  general  appearance  she  was  a  typical  chlorotic  subject.  She 
was  of  medium  height,  quite  fleshy,  but  not  inordinately  so ;  her 
hair  was  intermediate  in  color,  being  neither  dark  nor  light — in 
fact,  it  might  be  said  to  be  colorless ;  too  light  for  a  brunette,  too 
dark  for  a  blonde.  If  this  dark  shade  had  been  removed,  it  would 
have  been  hair  of  a  dark-flaxen  color ;  the  eyes  were  a  gray-blue  and 
very  clear ;  the  sclerotic  coat  pearly  white ;  the  skin  remarkably 
smooth  and  white.  The  face  was  pale,  with  that  greenish-yellow 
hue  which  must  be  seen  to  be  fully  appreciated.  This  color  of  the 
face  differs  from  the  yellow,  dry  skin  of  the  cacliectic  subject,  the 
pallor  of  ansemia,  and  the  bronze  of  sunburn.  Few  blood-vessels 
were  visible  on  the  face  or  hands,  and  these  were  very  small.  The 
pulse  was  about  eighty,  but  small,  more  like  that  of  a  child.  The 
heart-sounds  were  very  clear  and  distinct,  but  the  impulse  was  weak. 
The  area  of  cardiac  dullness  was  apparently  smaller  than  usual,  but 
this  was  difficult  to  make  out,  owing  to  the  mammary  glands  being 
large.  At  the  time  of  my  first  examination  she  was  feeling  more 
than  usually  languid  and  weak  because  of  indigestion  and  constipa- 
tion, which  had  troubled  her  for  several  weeks.  Her  tongue  was 
coated,  and  her  appetite  poor.  On  walking  up-stairs  quickly  she 
suffered  from  "  want  of  breath."  If  she  stooped  down  and  rose 
suddenly,  she  had  vertigo.  Toward  night  her  ankles  became 
slightly  swollen.  Her  sleep  was  often  disturbed  by  dreams.  In  dis- 
position she  was  a  little  sluggish,  good-natured,  and  generally  cheer- 
ful, with  occasional  attacks  of  mental  depression,  which  occurred 
usually  at  the  menstrual  period. 

The  pelvic  organs  were  normal  as  regards  general  nutrition,  ex- 
cept that  the  mucous  membrane  was  anaemic.  The  position  of  the 
uterus  was  normal.  The  sound  showed  the  cavity  of  the  uterus  to 
be  a  fraction  under  two  inches  in  length.  There  was  a  slight  leucor- 
rhcea.  The  menses  were  regular,  lasting  from  three  to  four  days, 
until  four  months  before  she  was  first  seen  by  me.  During  that 
time  she  had  had  a  leucorrhoeal  discharge'  at  the  menstrual  period, 
but  nothing  more. 

Treatment. — Pil.  hydrarg.,  gr.  x  ;  pulv.  ipecac,  gr.  j,  were  given 


MENSTRUATION  AND  ITS  DERANGEMENTS.  43 

at  bedtime,  followed  by  a  saline  laxative  in  the  morning.  After 
this,  a  teaspoonful  of  the  following  mixture  was  given,  well  diluted, 
before  meals  :  Strychnife  sulphatis,  gr.  ss. ;  acid,  hydrochlor.,  3j; 
tinct.  cardam.  comp.,  3  j ;  aquse  font.,  3  ij.  This  improved  her 
appetite,  and  her  strength  increased.  When  she  had  finished  the 
first  mixture,  the  following  was  given  :  Ferri  iodid.,  ±)j  ;  quinia3 
sulph.,  gr.  X  ;  ext.  belladonnas,  gr.  ij,  in  pil.  No.  xx,  one  before 
each  meal.  These  pills  were  taken  with  apparent  benefit  for  three 
weeks,  when  they  were  stopped,  and  the  following  was  ordered  : 
Tinct.  iodin.,  3  ij  ;  potass,  iodidi.,  3  ss. ;  syr.  simp.,  3  j  ;  aquse  font., 
3  ij  ;  one  teaspoonful,  after  meals,  in  water.  During  the  follow- 
ing six  weeks  she  took  the  pills  one  week,  and  the  next  week  the 
tincture  of  iodine  mixture,  alternating  regularly.  The  menses  ap- 
peared at  the  fifth  month  after  they  stopped,  but  were  scanty,  and 
lasted  only  two  days.  The  appetite  and  digestion  were  improved, 
and  the  anaemia  was  less  marked.  She  also  felt  much  stronger.  I 
then  prescribed  ferri  pyrophos.,  3  jss. ;  strychnise  sulph.,  gr.  ss. ;  liq. 
potass,  arsenit.,  3  j  ;  tr.  colomb.,  3  j  ;  aquse  font.,  3  ij.  Teaspoon- 
ful, in  water,  after  meals.  This  mixture  she  continued  to  take  for 
six  weeks  longer,  omitting  it  occasionally  for  a  few  days.  Dur- 
ing the  treatment  she  was  relieved,  as  far  as  possible,  from  all  care, 
took  light  exercise  in  the  open  air,  and  had  a  good  supply  of  nu- 
tritious food  in  great  variety,  being  restricted  only  in  the  quantity 
of  fluids,  sugar,  and  fats  that  she  took.  The  menses  continued  from 
this  time  onward  to  be  regular,  and  the  character  and  duration  of 
the  flow  were  the  same  as  they  had  been  in  her  best  former  health, 
but  were  not  improved.  For  several  years,  indeed  up  to  the  present 
time,  w^iich  is  now  five  years  since  she  was  first  seen,  she  has  been 
in  fair  health,  but  on  several  occasions,  when  she  ventured  to  do 
more  than  usual,  her  digestion  became  deranged  and  her  appetite 
poor.  Anaemia  has  become  more  marked,  and  the  menses  have 
diminished,  but  she  has  promptly  applied  for  treatment,  and  the 
use  of  tonics  has  restored  her  to  her  usual  rather  low  standard  of 
liealth. 

Comments. — This  history  shows  that  the  patient  was  not  cured 
of  her  chlorosis,  but  only  relieved  from  intercurrent  attacks  of 
malnutrition  and  the  consequent  imperfect  menstruation  which 
she  had. 

This  is  the  history  of  the  great  majority  of  such  cases  when  they 
come  under  observation  and  treatment  after  puberty.  This  shows 
that  the  whole  character  of  the  organization  is  below  the  highest 
standard,  and  hence  there  is  a  tendency  to  break  down  under  oi-di- 


44  DISEASES  OF  WOMEN. 

nary  taxation,  and  the  physician  can  do  no  more  than  restore  the 
patient  to  her  nsnal  decree  of  health. 

Chlorosis  treated  before  Puberty  with  apparently  Good  Results. — 
A  schoolgirl,  fourteen  years  old,  large  enough  for  her  age,  and  un- 
usually fleshy,  was  brought  to  me  on  account  of  loss  of  appetite  and 
constipation.  There  was  no  evidence  of  puberty,  except  that  her 
breasts  were  large,  but  they  were  mostly  made  up  of  adipose  tissue. 
Her  general  appearance,  color  of  li^ir  and  eyes,  small  heart  and 
blood-vessels,  white  skin,  jiale  face,  and  disinclination  to  active  exer- 
cise, indicated  chlorosis.  Nothing  was  lacking  but  the  usual  anaemia 
and  peculiar  color  of  the  face  to  make  the  case  a  type  of  chlorosis. 
She  was  directed  to  give  up  some  of  her  school  duties  and  devote 
more  time  to  systematic  muscular  exercise  and  out-of-door  life,  to 
abstain  from  fat  meat,  sugar,  and  butter,  of  all  of  which  she  was  un- 
usually fond,  and  to  live  upon  lean  animal  food,  fish,  eggs,  oatmeal, 
fruit,  and  brown  bread.  To  relieve  her  constipation  I  prescribed 
quin.  sulph.,  3  j  ;  ext.  belladonna,  gr.  ij  ;  ext.  colocynth.  comp.,  gr. 
X,  in  pil.  No.  xx ;  one  immediately  before  each  meal.  At  the  end 
of  two  weeks  the  bowels  were  acting  too  freely.  One  pill,  night 
and  morning,  before  meals,  was  ordered.  These  answered  for  a 
time,  but  in  three  weeks  it  was  found  that  one  pill  was  all  that  was 
required,  and  at  the  end  of  two  months  from  the  time  she  came 
under  treatment,  pills  were  given  up  altogether.  She  was  then  put 
upon  tlie  following  : 

]^     Ilydrarg.  chloridi  corrosivi gr.  j. 

Liquor  arsenici  chloridi f  3  j. 

Tr.  ferri  chloridi. 

Acid,  hydrochloric,  diluti ilil  f  3  iv. 

Syrupi  simplicis 3  ij. 

AqutB q.  s.  ad  §  vj. 

M.    Sig. :  A  dessertspoonful,  well  diluted,  after  each  meal. 

This  is  known  as  the  mixture  of  the  four  chlorides,  and  is  said 
to  have  been  first  used  by  Tilt,  of  London,  and  was  introduced  to 
the  jirofession  of  Philadelphia  by  the  late  Dr.  A.  II.  Smith.  This 
medicine  was  given  for  one  month,  then  omitted  for  two  weeks,  and 
again  taken  for  one  month.  After  this,  she  was  given  iodide  of 
iron  in  small  doses  for  two  months.  In  summer  she  was  sent  to  the 
mountains,  and  encouraged  to  ramble  in  the  open  air,  to  drive,  and 
occasionally  ride  on  horseback.  The  diet  that  was  first  recom- 
mended was  continued,  except  that  she  occasionally  indulged  her 
fancy  for  sweets. 


MENSTRUATION  AND   ITS   DERANGEMENTS.  ,    45 

Under  this  course  of  treatment  she  lost  flesh,  and  grew  taller  and 
stronger.  Her  pulse  was  markedly  improved,  and  her  appetite  con- 
tinued to  be  very  good.  At  the  age  of  fifteen  years  and  three 
months  she  showed  evidences  of  maturity,  and  simultaneously  her 
appetite  became  somewhat  capricious ;  backache  and  headache  occa- 
sionally troubled  her,  and  she  was  at  times  depressed.  The  mixture 
of  the  chlorides  was  resumed  and  continued  for  one  month.  Her 
usual  order  of  life  was  continued,  except  that  she  did  not  ride  on 
horseback,  and  was  carefully  guarded  from  overtaxation,  mental 
and  physical.  The  menses  appeared  and  continued  for  four  days 
normally,  and  were  not  attended  with  great  pain.  In  six  weeks  the 
flow  returned,  and  lasted  the  same  length  of  time.  From  this  on- 
ward for  one  year  the  menses  were  normal.  After  that,  she  went 
to  a  higher  school,  and  tried  to  make  up  for  lost  time  in  her  studies. 
During  this  time  she  was  not  seen,  i.  e.,  for  about  one  year  and  four 
months.  Then  she  called  upon  me,  and  the  following  history  was 
obtained  :  Her  appetite  was  capricious,-  and  her  bowels  constipated  ; 
she  had  headache  often ;  slept  in  a  restless,  dreamy  way ;  had  pain 
in  the  prsecordial  region  and  dorsal  portion  of  the  spine  ;  was  easily 
frightened,  and  had  palpitation  of  the  heart  on  taking  exercise. 
The  menses  were  delayed  for  two  weeks,  and  when  they  returned 
the  flow  was  scanty,  and  lasted  only  three  days.  At  this  time  she 
had  a  more  marked  chlorotic  appearance  of  the  face  than  at  any 
time  before.  The  pills  previously  prescribed  were  given  to  keep 
the  bowels  regular,  and  the  mixture  of  chlorides  was  given  for  one 
month,  and  after  that  she  was  given  twenty  minims  of  the  sirup  of 
the  iodide  of  iron  three  times  a  day.  The  thought  of  falling  behind 
in  her  studies  grieved  her  so  much  that  she  was  placed  under  the 
care  of  a  governess,  who  interested  her  in  her  studies  but  did  not 
harass  her. 

The  menses  became  normal  again,  and  she  regained  her  general 
health,  and  has  since  continued  well.  She  is  at  this  time  married, 
and  the  mother  of  one  child. 

Comments. — It  is  not  possible  to  prove  that  this  patient  would 
have  become  a  well-defined  chlorotic  subject,  but  I  believe  that  she 
would,  had  she  been  neglected,  as  most  of  these  cases  are.  In  my 
clinical  records  I  find  several  cases  of  this  kind,  and  most  of  them 
have  been  greatly  aided  by  care  and  medication  similar  to  that  used 
in  the  management  of  this  case.  The  benefit  of  treatment  has  been 
most  marked  in  those  who  came  under  care  early  in  life.  Those 
who  had  no  treatment  until  after  puberty,  and  were  suffering  from 
all  the  symptoms  of  typical  cases  were  improved  by  treatment,  so 


46  DISEASES  OP  WOMEN. 

far  as  obtaining  relief  from  deranged  digestion  and  neuralgia,  and 
to  some  extent  from  anaemia,  but  tbej  still  maintained  their  consti- 
tutional peculiarities,  with  a  tendency  to  recurrence  of  the  anemia 
and  menstrual  derangements. 

In  those  who  married  early  and  bore  children  (a  not  unusual 
thing  for  those  in  whom  chlorosis  is  not  marked),  there  was  a  notice- 
able predisposition  to  albuminuria  and  puerperal  convulsions.  Snch 
cases  also  tend  to  inertia  of  the  uterus  and  post-partum  hsemorrhage. 
Thev  very  generally  suffer  from  aniemia  and  nervous  exhaustion 
during  lactation. 

A  Marked  Case  of  Chlorosis,  complicated  with  Gastric  Derange- 
ment.— The  patient  was  a  domestic,  twenty-three  years  of  age,  and 
presented  all  the  characteristics  of  chlorosis  in  a  typical  degree. 

She  had  suffered  repeatedly  from  amenorrhcea,  but  had  always 
responded  to  tonics  sufficiently  to  resume  her  duties  in  a  few 
weeks. 

She  was  attacked  with  vomiting,  her  strength  failed  rapidly, 
and  she  was  unable  to  leave  her  room  for  weeks.  When  she  took 
food  it  gave  her  distress,  until  it  was  rejected.  Sometimes  food 
would  be  vomited  after  having  been  retained  in  the  stomach  nearly 
an  hour,  but  it  was  not  in  any  degree  digested. 

Gastric  ulcer  was  suspected,  although  she  had  never  vomited 
blood.  She  was  given  peptonized  milk  as  the  only  food.  This^  she 
retained  in  increasing  quantity,  and  gradually  regained  her  usual 
health. 

Comments. — This  case  shows  the  strong  characteristics  of  ex- 
treme ansemia  in  chlorotic  patients.  I  believe  that  the  stomach  is 
unable  to  digest  food  because  of  the  anaemia,  and  this  causes  the 
vomiting.  In  such  cases  the  peptonized  food  is  of  the  greatest 
possil)le  value. 

Menstrual  Derangements  from  Causes  independent  of  the  Sexual 
Organs.— This  class  of  menstrual  disorders  is  closely  related,  in  the 
matter  of  diagnosis,  to  those  deranged  functions  of  the  uterus  due 
to  anatomical  lesions ;  hence  the  subject  may  appropriately  be  dis- 
cussed here.  It  is  only  necessary  to  call  to  mind  all  the  condi- 
tions necessary  to  menstruation  to  see  plainly  that  constitutional 
diseases,  acute  and  chronic,  as  well  as  functional  disturbances  of 
the  nervous  system,  would  act  unfavorably  upon  the  functions  of 
the  genital  system.  As  a  general  rule,  any  constitutional  affec- 
tion wliich  impairs  nutrition  and  reduces  strength  very  decidedly 
will  affect  menstruation.  This  is  certainly  the  case  when  the  gen- 
eral depression  continues  for  any  great  length  of  time.     The  best 


MENSTRUATION  AND  ITS  DERANGEMENTS.  47 

example  of  tliis  is  seen  in  phthisis  puhnonahs.  In  the  advanced 
stages  of  this  disease  the  menses  usually  stop  altogether.  The 
uterine  function  ceases  under  these  circumstances,  simply  because 
the  general  system  is  unable  to  sustain  it.  In  acute  diseases,  such  as 
pneumonia  or  typhoid  fever,  menstruation  may  be  interrupted  for  a 
period  or  two,  but  it  usually  reappears  when  the  patient  fully  re- 
covers from  the  constitutional  disease.  On  the  other  hand,  in  degen- 
erative diseases,  such  as  organic  diseases  of  the  liver,  lungs,  heart,  or 
kidneys,  the  menses  often  become  irregular  and  scanty  or  profuse, 
and  finally  stop  altogether  during  the  remainder  of  the  invalid's 
life.  So,  also,  severe  shocks  or  over-taxation  from  shock,  exposure 
to  cold,  fear,  grief,  and  extreme  mental  work,  may  cause  the  menses 
to  temporarily  cease.  Again,  either  of  the  constitutional  conditions 
referred  to  above  may  retard  the  first  appearance  of  the  menses  if 
they  are  active  at  the  period  of  puberty,  even  though  the  develop- 
ment and  growth  of  the  genital  organs  may  not  be  arrested. 

Amenorrhcea,  or  delay  of  the  advent  of  the  menstrual  function,  is 
the  rule  when  these  causes  exist.  There  are  exceptions  to  this  rule, 
as,  for  example,  valvular  lesions  of  the  heart  and  cirrhosis  of  the 
liver,  may  cause  menorrhagia,  and  nervous  derangements  may  cause 
premature  menstruation. 

The  diagnosis  in  such  cases  is  usually  easy.  By  the  time  that  the 
uterine  function  becomes  deranged,  the  constitutional  disease  is  so 
far  advanced  as  to  be  easily  recognized.  One  is  greatly  aided  in 
diagnosis  when  the  menses  have  for  a  time  been  regular,  but  become 
deranged  without  any  disease  of  the  sexual  organs  being  present. 

When  amenorrhcea  occurs  as  the  result  of  some  constitutional 
disease  that  is  incurable,  the  special  interest  of  the  gynecologist  ends 
when  the  diagnosis  is  made,  because  no  special  treatment  is  of  any 
avail.  On  the  other  hand,  in  menorrhagia,  when  due  to  chronic 
affections  of  the  heart,  liver,  or  kidneys,  something  may  be  accom- 
plished in  the  way  of  modifying  the  trouble,  and  thereby  prolonging 
the  life  of  the  patient.  Here  also  the  management  is  general,  not 
special,  and  hence  does  not  come  within  the  scope  of  the  present 
work. 

Premature  Menstruation  from  Deranged  Conditions  of  Life  and 
Deranged  Innervation. — The  rule  that  the  menses  should  appear  after 
the  completion  of  development  which  occurs  at  puberty  is  violated  in 
the  cases  now  under  discussion,  because  the  uterine  function  is  taken 
up  before  the  general  development  is  completed.  In  determining 
the  question  of  premature  menstruation  it  is  necessary  to  ascertain 
whether  the  patient  is  suflSciently  mature  in  development  to  render 


48  DISEASES  OF  WOMEN. 

lier  capable  of  taking  up  this  uteiiae  function.  She  may  be  old 
enough,  but  not  developed  enough  in  her  general  system.  The 
causes  of  this  too  early  appearance  of  the  menses  are  various.  It 
seems  that  opposite  conditions  of  life  produce  the  same  results.  Bad 
air,  poor  food,  overwork,  and  impure  social  surroundings,  have  this 
ill  effect ;  at  least,  cases  frequently  occur  among  those  who  are  so 
poor  that  they  fail  to  obtain  all  that  is  necessary  to  health. 

This  fact  regarding  the  premature  activity  of  the  sexual  system 
appears  to  arise  from  a  law  in  Nature,  which  is  that  all  plants  and 
animals  placed  in  unfavorable  environments  devote  more  of  their 
energies  to  reproduction  than  those  that  are  more  favorably  situated. 
It  would  appear  as  if  they  appreciated  their  danger  of  being  crowded 
out  of  existence,  and  hence  struggle  more  vigorously  to  procreate. 
Yiewing  the  subject  in  this  light  it  may  be  said,  to  speak  figurative- 
ly, that  girls  and  plants  while  stunted  by  living  in  poor  soil  run  to 
seed. 

The  same  premature  menstruation  occasionally  occurs  among 
those  who  are  favorably  situated  in  regard  to  the  necessities  of  animal 
life.  Those  who  have  the  means  of  supplying  all  their  wants,  real 
or  imaginary,  and  lack  intelligence  and  culture,  which  would  enable 
them  to  profitably  occupy  their  minds,  suffer  like  the  poor.  This 
would  indicate  that  the  real  cause  of  the  sexual  precocity  was 
deranged  innervation. 

Delay  of  the  advent  of  menstruation  occurs  among  those  who 
are  situated  apparently  like  those  just  described.  The  girl  who 
labors  out-of-doors  and  develops  great  muscular  strength  may  fail  to 
menstruate  until  past  the  usual  age.  So,  also,  the  same  thing  occurs 
to  some  who  live  in  luxury.  In  such  cases  the  cause  is,  no  doubt, 
imperfect  innervation.  In  the  class  first  described  attention  is  given 
to  the  genital  system  prematurely,  M'hile  in  the  second  class  the 
social  element  of  life  is  neglected. 

The  general  management  of  these  patients  consists  in  removing 
the  cause,  if  possible,  by  placing  them  in  such  healthful  surround- 
ings as  will  prevent  the  evil.  This,  however,  is  not  always  in  the 
power  of  the  physician,  and  he  has  to  meet  the  wants  of  those  really 
in  suffering.  When  the  menstrual  function  has  been  established, 
though  prematurely,  no  effort  should  be  made  to  sto])  it.  Attention 
should  be  given  wholly  to  building  up  the  general  system.  The 
overworked  should  obtain  rest  and  good  food.  The  nervous  system 
should  have  attention.  The  perverted  mind-action  should  be  cor- 
rected by  wholesome  brain-occupation.  The  indolent  should  be 
stimulated  to   greater  activity.     Society  is  desirable   for  those  in 


MENSTRUATION  AND  ITS   DERANGEMENTS.  49 

"whom  the  menses  are  delayed,  and  quiet  country  life  should  he  pre- 
scribed for  those  who  have  suffered  from  premature  social  excite- 
ment. 

ILLUSTRATIVE    CASES. 

Premature  Meastruation  from  Deranged  Innervation,  produced  by 
Luxurious  Surroundings  and  Over-Stimulation  of  the  Nervous  System. 

— The  patient  was  an  only  daughter  of  wealthy  parents,  and  was  al- 
ways a  bright  child  and  greatly  indulged  by  her  family  and  friends. 
She  was  treated  at  home  and  at  school  more  like  a  young  lady  than 
a  child,  and  was  almost  constantly  in  company.  In  the  parlor  and 
drawing-room  she  associated  with  her  elders,  and  was  devoted  to  the 
opera  and  theatre  from  the  time  she  was  big  enough  to  visit  such 
places  of  amusement.  She  often  suffered  from  headaches  and  indi- 
gestion, and  was  always  excitable  mentally,  and  at  times  peevish 
and  irritable.  She  menstruated  first  at  eleven  years  quite  freely, 
and  the  How  lasted  four  days.  At  this  time  she  had  all  the  ap- 
pearances of  girlhood.  The  mammary  glands  were  slightly  de- 
veloped, but  her  foi-m  had  not  attained  anything  like  maturity. 
Trom  this  time  onward  she  menstruated  regularly  and  normally. 
She  was  first  seen  during  her  first  menstrual  period,  and  then  her 
parents  were  advised  to  change  all  her  habits  of  life.  She  was  taken 
to  a  quiet  country  home  in  summer,  instead  of  a  fashionable  hotel 
at  which  she  had  previously  passed  her  summers,  and  permitted  to 
spend  her  time  in  the  fields  with  her  attendant,  who  was  a  woman 
of  good  common  sense  and  experienced  in  the  proper  care  of  chih 
•dren.  All  excitement  was  kept  from  her,  and  her  habits  of  life 
xnade  regular  and  natural.  In  winter  she  was  permitted  to  attend 
school  for  half  the  time,  and  the  rest  of  the  day  was  devoted  to  draw- 
ing, reading,  and  gymnastic  exercises.  Abundance  of  sleep  in  the 
early  part  of  the  night  was  directed,  and  cold  bathing  every  morn- 
ing. No  medicine  was  given.  Under  this  general  management  she 
grew  in  size  quite  rapidly,  and  by  the  time  she  was  sixteen  years  old 
she  was  a  well-developed  young  lady,  and  enjoyed  very  good  health. 
Premature  Menstruation  occurring  in  a  Poor,  Ill-cared-for  Girl, 
"from  the  Lowest  Grade  of  Society. — This  patient,  a  hospital  one,  was 
ten  years  and  five  months  old  when  she  first  menstruated.  She  lived 
in  one  of  the  poorest  tenement  regions  of  the  city.  Her  father  was 
:a  drunkard,  and  left  his  family  to  the  care  of  the  mother,  who  was 
a  washer- woman.  This  girl  lived  by  begging  while  very  small,  and 
when  older  worked  in  a  tobacco-factory.  She  was  thirteen  years  old 
when  seen  in  the  hospital,  and  had  menstruated  regularly  from  the 
-age  mentioned.  Her  general  health  was  poor,  very  poor  ;  she  had 
5  , 


50  DISEASES   OF   WOMEN. 

the  appearance  of  an  undersized,  ill-fed,  undeveloped  girl,  quite 
ignorant,  and  doubtless  of  low  moral  nature.  She  was  in  the  hospi- 
tal to  be  treated  for  specific  vaginitis. 

Delayed  Menstruation  in  a  Girl  who  was  large,  strong,  and  in  good 
health. — The  daughter  of  a  poor  farmer  had  spent  most  of  her  life 
in  doing  out-door  farm-work.  Her  food  was  milk,  oatmeal,  and 
potatoes.  She  was  large,  muscular,  and  full-blooded.  Between  six- 
teen and  seventeen  years  of  age  she  developed  the  characteristics  of 
womanhood,  but  at  the  age  of  seventeen  years  and  six  months  the 
menses  had  not  appeared.  She  was  then  suffering  from  occasional 
headaches,  backache,  drowsiness,  constipation,  and  general  indisposi- 
tion. These  symptoms,  with  delay  in  the  appearance  of  the  menses, 
caused  her  to  seek  advice.  She  was  very  muscular  and  tine-featured. 
The  pulse  was  full  and  strong,  the  mammary  glands  well  developed, 
and  her  figure  was  markedly  of  the  female  type.  A  teaspoon ful  of 
sulphate  of  magnesia  and  half  a  teaspoonful  of  table-salt  in  a  goblet- 
ful  of  water  were  ordered  every  morning  an  hour  before  breakfast. 
The  liberal  use  of  animal  food  was  directed.  She  was  advised  to 
take  a  vacation  from  her  hard  labor  on  the  farm,  and  visit  her  rela- 
tions who  were  more  comfortably  situated.  These  directions  were 
followed  out  for  a  month,  with  no  effect,  except  to  relieve  her  con- 
stipation. The  saline  mixture  was  stopped  and  the  following  or- 
dered:  Quinine  sulph.,  3i;  ext.  belladonnae,  gr.  ij ;  ext.  aloes  aq., 
gr.  iv.  Pil.  no.  xx  :  one  before  each  meal.  When  the  headache  and 
general  feelings  of  malaise  returned,  I  prescribed  spiritus  ammon. 
arom.,  5«^s;  aquae  camph.,  3  i jss  —  a  dessertspoonful  every  three 
hours.  At  the  end  of  two  months,  she  began  to  menstruate. 
There  was  considerable  pain  accompanying  the  flow,  which  was 
rather  dark  in  color.  The  pills  were  continued,  but  she  was  soon 
able  to  give  up  one  a  day,  and  then  two,  and  finally  ceased  taking 
them  altogether.  At  each  period,  which  recurred  regularly,  she  took 
the  ammonia  and  camphor  mixture.  Six  months  after  her  first  men- 
struation she  reported  that  she  was  regular  and  (piite  Avell. 

Delayed  Menstruation  in  a  Patient  of  Marked  Phlegmatic  Tem- 
perament and  Indolent  Habits. — The  daughter  of  wealthy  parents,  of 
average  height  but  quite  stout,  and  presenting  all  the  evidences  of 
the  phlegmatic  temperament,  was  brought  to  me  at  the  age  of  six- 
teen, because  she  had  not  menstruated.  I  learned  that  she  lived 
well,  slept  much,  and  took  but  little  exercise,  mental  or  physical. 
She  had  all  the  appearance  of  having  arrived  at  puberty,  and  for  one 
year  had  had  a  slight  leucorrhrea,  but  no  menstrual  How.  She  was 
ordered  to  take  lessons  in  horseback-riding,  and  to  walk  for  half  an 


MENSTRUATION   AND   ITS  DERANGEMENTS.  51 

hour  twice  a  day.  A  Turkish  bath  with  thorough  massage  three 
times  a  week  was  also  directed  ;  I  prescribed  potass,  permanganat.,  gr. 
XXX,  in  piL  no.  xxx :  one  three  times  a  day,  before  meals.  This 
treatment  was  contiinied  for  about  three  months,  excepting  that  at 
the  end  of  one  month  the  pills  were  omitted  for  three  weeks  and 
again  taken  up,  and  continued  until  the  end  of  the  three  months. 
At  this  time  she  menstruated,  and  continued  to  do  so  regularly  after- 
ward. The  ilow  was  never  very  free,  but  it  continued  about  live 
days  each  time. 

Irregular  Menstruation  from  Deranged  Innervation  and  Anaemia. — 
This  patient  was  twenty-live  years  of  age,  of  sanguine,  nervous  tem- 
perament, and  had  been  in  good  health  up  to  the  time  that  she 
was  nineteen.  She  menstruated  first  at  iifteen,  and  continued  to 
do  so  regularly,  until  the  year  that  she  graduated  in  school,  when 
nineteen  years  old.  Dm-ing  the  latter  half  of  her  last  year  in 
school  her  menses  became  irregular,  six  weeks  or  two  months  in- 
tervening between  the  periods.  At  this  time  her  health  became 
much  reduced,  but  after  leaving  school  she  improved  generally,  and 
the  menses  became  regular.  At  twenty-four  years  of  age  she  began  to 
indulge  to  excess  her  love  for  music  and  painting,  which  had  always 
been  favorite  studies  with  her.  Dyspepsia  and  general  debility  fol- 
lowed, and  the  menses  became  again  irregular.  She  first  came  under 
my  care  at  twenty-five,  and  at  that  time  the  menses  had  been  absent 
for  three  months.  She  was  quite  anaemic,  and  her  nervous  system 
much  exhausted.  She  was  ordered  to  give  up  her  favorite  studies, 
and  devote  herself  to  regaining  her  lost  health.  She  was  directed  to 
take  three  regular  meals  a  day,  and  in  the  forenoon  a  cup  of  beef- 
tea  or  a  glass  of  milk,  and  in  the  afternoon  extract  of  malt,  or  else 
peptonized  milk  and  a  glass  of  claret.  Before  her  regular  meals  she 
was  given  tr.  nucis  vom.,  ^^,  iij  ;  vini  ipecac,  ^J  ij,  in  a  wine-glass 
of  warm  water.  This  improved-  her  appetite.  After  meals  she 
took  a  teaspoonful  of  the  following:  Tr.  ferri  chlor.,  3 iij;  lic[-  ai*- 
senic.  hydrochlor.,  3  j  ;  spiritns  limonis,  3  ss ;  syr.  simp.,  ^  j  ;  aquae 
font.,  ^ij.  This  treatment  was  continued  for  three  weeks,  with  the 
effect  of  improving  her  general  condition,  but  the  menses  did  not 
return.  In  place  of  the  iron-mixture  she  was  given  the  permangan- 
ate of  potash  pills,  but  without  any  apparent  effect.  Iron  was  again 
given,  and  the  menses  returned  after  she  had  been  six  weeks  under 
treatment.  She  continued  to  be  irregular,  some  five  and  six  weeks 
between  the  periods,  but,  as  her  general  health  improved,  the  inter- 
menstrual, periods  became  shorter,  until  the  normal  time  was  estab- 
lished.    Altogether  she  was  under  observation  for  one  year,  and 


52  DISEASES   OF  WOMEN". 

during  most  of  that  time  she  took  tonics  containing  some  form  of 
iron.  Citrate  of  iron  and  quinine,  iodide  of  iron  and  whisky,  po- 
tassio-tartrate  of  iron  and  wine,  were  the  chief  preparations  given. 

Suppression  of  the  Menses  from  Acute  Derangement  of  Innervation. 
— A  hidy,  twenty-one  years  of  age,  of  excellent  physique,  who  had 
menstruated  with  great  regularity  from  the  time  that  she  was  lifteen 
years  of  age,  left  home  for  the  lirst  time  in  her  life  to  visit  some 
friends  in  a  far-distant  city.  On  the  day  that  her  menses  should 
have  appeared,  she  was  alone  and  not  accustomed  to  traveling,  and 
she  hecame  much  excited  over  her  journey,  and  was  greatly  fatigued 
when  she  reached  her  friends.  She  could  not  sleep  on  the  cars,  and 
her  appetite  left  her  almost  altogether.  I  was  called  to  her  on  the 
third  day  after  she  left  home,  and  a  few  hours  after  her  arrival. 
The  menses  had  not  appeared  ;  her  head  ached  very  acutely  ;  her  face 
was  flushed ;  skin  dry  and  pulse  excited.  The  temperature  was 
100°  Fahr.  I  ordered  a  hot  foot-bath  and  the  forehead  bathed  with 
alcohol,  and  prescribed  ammon.  bromid.,  gr.  xv,  tinct.  aconit.  rad.,  tt], 
i],  every  three  hours  in  a  small  glass  of  Vichy  water.  She  was  kejit 
quiet  in  bed.  After  taking  three  doses  of  the  medicine,  she  slept 
fairly  well  during  the  night.  Next  morning  her  headaclie  was 
almost  gone ;  her  pulse  was  quiet ;  flushing  of  the  face  less  notice- 
able, and  she  had  an  appetite,  but  the  menses  had  not  come.  I  pre- 
scribed camph.,  gr.  v  ;  ext.  lupul.,  gr.  x  ;  ext.  valerian,  gr.,  x  :  in  cap- 
sul.  Xo.  X.  One  to  be  given  every  three  hours  during  the  day  and 
following  night  if  awake.  She  slept  well  in  the  night  and  next 
morning  began  to  menstruate. 

Amenorrhcea  from  Chronic  Derangements  of  Innervation. — This 
patient  was  twenty-four  years  of  age,  of  good  constitution,  and  had 
menstruated  normally  until  six  months  before  the  taking  of  this  his- 
tory. In  that  time  she  lost  her  motlier,  to  whom  she  was  greatly 
devoted.  This  prostrated  her  with  grief,  and  about  the  same  time 
her  father  suffered  reverses  in  business,  so  that  my  patient,  who  had 
up  to  this  time  lived  in  luxury,  was  obliged  to  seek  employment  to 
support  herself.  From  the  death  of  her  mother  she  failed  to  men- 
struate until  nine  months  aftei'ward.  She  was  greatly  depressed  \\\) 
to  the  time  that  she  began  treatment,  and,  although  her  general 
health  was  good,  she  was  melancholy,  and  was  greatly  annoyed  by 
her  new  occupation  and  changed  social  position.  The  amenorrluini 
was  a  great  source  of  anxiety  to  her,  because  some  of  her  friends 
had  told  her  that  it  was  sure  to  lead  to  consumption.  I  fully  assured 
her  that  she  was  in  no  danger,  and  that  her  recovery  was  certain. 
This  alone  was  a  decided  tonico 


MENSTRUATION  AND  ITS   DERANGEMENTS.  53 

I  ordered  the  following :  Strychnise  sulphatis,  gr.  ss ;  tr.  cannabis 
Indie,  3  ij ;  tr.  card,  comp.,  ^  j  ;  aqnge  font.,  §  ij-  Teaspoonful  be- 
fore meals.  This  she  continued  for  two  weeks.  I  tlien  ordered 
Parrish's  compound  sirup  of  phosphates,  a  teaspoonful,  after  meals, 
in  water.  This  was  taken  regularly  for  three  weeks,  when  the  fol- 
lowing was  given  instead:  Quin.  sulph.,  3ij;  ext.  valerian.,  3j; 
ext.  cannabis  Indic,  gr.  v :  in  capsul.  No.  xxi.  One  before  meals, 
and  a  glass  of  red  wine  after  meals.  This  was  continued  for  over  a 
month.  During  this  time  she  was  induced  to  take  more  out-of-dooi- 
exercise,  and  divert  her  mind  by  light  amusements.  General  gym- 
nastic exercise  was  taken,  but  not  systematically  nor  regularly.  When 
this  course  of  treatment  had  been  employed  she  menstruated,  and 
from  this  time  on  was  regular  and  well.  In  general  spirits  she 
began  to  improve  considerably  before  the  menses  returned,  but  after- 
ward her  progress  was  rapid,  and  recovery  complete.  This  case  will 
suffice  to  illustrate  this  cause  of  amenorrhoea. 

Imperforate  Hymen  causing  Non-appearance  of  the  Menstrual  Flow. 
— This  affection  should  be  classed  with  atresia  of  the  vagina,  but  is 
given  here  because  the  history  of  such  cases  resembles  delayed  men- 
struation from  some  of  the  causes  just  given.  This  condition  is 
usually  unnoticed  until  puberty,  when  all  the  evidences  of  menstrua- 
tion appear  except  the  flow,  which  is  arrested  by  the  imperforate, 
thickened  hymen.  The  fluid  which  accumulates  at  each  menstrual 
period  distends  the  vagina  first  and  then  the  uterus,  the  distention 
increasing  at  each  period.  Pelvic  tenesmus,  a  feeling  of  distention 
of  the  vagina,  and  enlargement  of  the  abdomen  are  the  chief  symp- 
toms and  signs  presented. 

In  course  of  several  months  the  suffering  causes  the  patient  to 
seek  relief,  when  a  diagnosis  can  be  made  by  physical  examination. 
The  treatment  is  to  evacuate  the  fluid  by  opening  through  the  hymen. 
This  is  attended  with  great  danger,  owing  to  the  tendency  to  inflam- 
mation and  septicaemia.  The  fluid  is  dark,  thick,  and  tarry  in  char- 
acter, and  decomposes  quickly  on  exposure  to  air.  This  and  the 
irritation  of  the  vagina  and  uterus  may  account  for  the  tendency  to 
inflammation  and  blood-poisoning.  The  method  of  treatment  found, 
in  past  times,  to  be  the  safest  was  to  make  a  small  opening,  evacuate 
very  slowly,  and  subsequently  enlarge  the  opening,  or  exsect  the 
hymen  entirely.  Another  method  is  to  make  a  free  incision  with 
the  incandescent  knife  of  a  thermo-cautery,  evacuate  rapidly,  and 
wash  out  the  uterus  and  vagina.  This  method  has  proved  to  be 
safer  since  the  days  of  antiseptic  surgerj^,  and  may  be  adopted. 


CHAPTER   IV. 

FLEXIONS    OF   THE    UTEKUS. 

I  coNsroER  flexion  of  the  uterus  as  a  deformity,  and  it  certain- 
ly belongs  to  that  order  of  pathological  conditions.  The  pathol- 
ogy, cause,  symptoms,  physical  signs,  and  treatment  of  flexion,  all 
differ  from  version,  hence  a  clear  distinction  between  the  two  should 
be  made  in  order  to  avoid  confusion. 

Anteflexion  of  the  uterus  is  most  frequently  a  congenital  deform- 
ity, some  arrest  or  derangement  of  development  giving  rise  to  the 
malformation.  Occasionally  it  results  from  disease,  inflammatory 
or  degenerative,  which  weakens  the  uterus  at  a  certain  point  and 
permits  it  to  become  bent  upon  itself.  I  shall  limit  myself  to  the 
consideration  of  flexion  occurring  as  the  result  of  these  two  causes, 
and  shall  purposely  omit  all  deformities  caused  by  pre-existing  affec- 
tions, such  as  adhesions  of  the  uterine  body  to  other  pelvic  organs, 
tumors  in  the  walls  of  the  uterus  which  by  their  weight  bend  the 
uterus,  and  pressure  of  abdominal  tumors  which  crowd  the  uterine 
body  to  either  side.  Whenever  flexion  is  produced  by  some  such 
antecedent  disease,  I  prefer  to  consider  it  as  a  complication  of  the 
primary  affection,  rather  than  to  discuss  it  as  a  distinct  condition. 

The  point  of  flexion  is  at  the  junction  of  the  body  and  cervix. 
It  may  occnr  above  or  below  that  point,  but  only  as  a  very  unim- 
portant exception  to  the  rule.  The  several  forms  of  flexion  I  have 
denominated  first,  second,  and  third.  The  first  is  flexion  of  the 
body ;  the  second,  flexion  of  the  cervix ;  and  the  third,  flexion  of 
both  l)ody  and  cervix. 

Taking  the  ground  that  flexion  is  a  deformity,  it  may  naturally 
be  attributed  to  some  defect  of  development ;  and  in  order  to  un- 
derstand the  lesions  of  form  and  structure  arising  from  arrest  or 
derangement  of  development,  it  becomes  necessary  to  restate  the 
essential  points  in  that  process  as  relates  to  the  uterus. 

At  l)irth  the  uterus  and  vagina  are  joined  in  such  a  manner  that 

54 


FLEXIONS   OF  THE   UTERUS.  55 

tlie  cervix  uteri  projects  into  the  vagina  but  a  very  short  distance, 
and  about  equally  on  the  anterior  and  posterior  walls  of  the  vagina. 
After  birth  the  uterus  remains  without  change  until  puberty,  ex- 
cept during  the  time  of  second  dentition,  when  the  palma  plicata 
disappears  from  the  body  of  the  organ,  with  the  exception  of  one 
fold  which  runs  lengthwise.  The  body  increases  a  little  in  size,  so 
that  the  body  and  cervix  become  more  nearly  equal.  At  the  same 
time  the  organ  settles  down  into  the  pelvic  cavity,  and  the  cervix 
elongates  and  becomes  more  prominent  in  the  vagina. 

At  puberty  the  uterus  undergoes  secondary  development.  The 
■organ  increases  in  size,  this  being  especially  true  of  the  body.  Un- 
til puberty  the  uterus  differs  but  little  in  shape  from  that  of  the 
new-born  babe,  which  has  been  already  described  ;  but  at  the  time 
when  menstruation  or  functional  activity  of  the  reproductive  organs 
is  about  to  be  established,  it  assumes  the  form  and  structure  of  the 
mature  organ.  Suffice  it  to  say  that,  as  the  tissues  are  developed, 
they  become  denser,  giving  to  the  organ  the  firmness  necessary  to 
support  it  and  keep  it  from  bending  in  any  direction  by  its  own 
weight. 

There  are  two  anatomical  points  bearing  upon  the  subject  now 
under  consideration  to  which  I  desire  to  call  particular  attention : 

1.  The  position  or  relations  of  the  uterus  to  other  pelvic  organs 
at  birth,  during  girlhood,  and  after  puberty. 

2.  The  relations  of  the  cervix  uteri  and  the  vagina  at  the  com- 
pletion of  23rimary  formation  and  after  secondary  development. 

The  infantile  pelvis  is  relatively  narrower,  deeper,  and  less  curved 
than  the  adult ;  hence  the  canal  formed  by  the  uterus  and  vagina  is 
straighter  than  after  puberty.  The  small  size  of  the  infantile  uterus, 
the  thinness  of  its  walls,  and  flaccid  condition  of  its  tissues,  render  it 
capable  of  bending  forward  or  backward  according  to  circumstances. 
This  fact  may  account  for  the  variety  of  opinions  regarding  the 
position  of  the  uterus  previous  to  puberty.  At  birth  the  uterus  is 
high  up  in  the  pelvis,  but  settles  down  during  the  second  dentition, 
as  has  been  already  stated,  and  forms  with  the  vagina  the  arc  of  a 
smaller  circle,  having  its  concavity  forward ;  hence  the  greater 
liability  of  the  uterus  to  be  antefl.exed  or  anteverted  during  girl- 
hood, if  it  deviates  at  all ;  but,  according  to  Klob,  the  uterus  is 
neither  bent  forward  nor  backward  until  puberty. 

From  the  information  obtained  by  the  study  of  embryology  and 
the  anatomy  of  the  reproductive  organs,  one  must  necessarily  con- 
sider the  uterus  and  vagina  as  forming  one  canal.  The  peculiar  ar- 
rangement at  the  junction  of  these  organs  appears  as  if  formed  from 


56  DISEASES   OF   WOMEN. 

an  invagination,  the  upper  part  of  the  vagina  receiving  the  dupli- 
cation of  the  uterus  which  forms  the  vaginal  portion  of  the  cervix. 
This  invagination  is  very  slight  at  birth,  as  may  be  seen  by  referring 
to  any  normal  infantile  uterus.  The  projecting  portion  of  the  cervix 
at  this  period  is  about  equal,  anteriorly  and  posteriorly.  During 
the  period  of  second  dentition,  when  the  uterus  settles  down,  this 
portion  of  the  cervix  becomes  more  apparent  still.  It  will  also  be 
observed  that  the  posterior  wall  of  the  cer\dx  projects  a  little  farther 
than  the  anterior.  At  puberty,  when  the  sexual  organs  undergo 
secondary  development,  invagination  progresses  still  further,  and  the 
cervix  and  vagina  assume  the  relation  of  adult  maturity.  It  should 
be  noted  that  the  poi'tion  of  the  cervix  which  projects  into  the 
vagina  is  much  longer  posteriorly  than  anteriorly.  This  must  neces- 
sarily be  so,  to  some  extent,  from  the  fact  that  the  uterus  and  vagina 
form  an  arc  of  a  circle  corresponding  to  the  curve  of  the  pelvis ;  but 
the  difference  is  slightly  greater  than  is  necessary  to  make  the  curve 
form  part  of  a  circle.  Perhaps  it  would  be  more  correct  to  say  that 
the  junction  of  the  cervix  and  vagina  forms  an  obtuse  angle. 

I  am  thus  particular  in  describing  these  relations  of  the  uterus 
and  vagina,  because  I  hope  to  show  hereafter  that  arrest  or  derange- 
ment of  the  process  of  invagination  of  the  cervix  uteri  has  much  to 
do  in  causing  flexion. 

Anteflexion  of  the  Uterus. — I  prefer  to  consider  anteflexion  of 
the  uterus  a  deformity,  although  it  is  usually  called  a  displacement, 
because  it  certainly  is  a  lesion  of  form  rather  than  position. 

The  pathology,  cause,  symptoms,  physical  signs,  and  treatment  of 
flexion  all  differ  from  those  of  displacements  of  the  uterus,  hence 
the  clearer  that  the  distinction  between  the  two  can  be  made  the 
better. 

The  deformities  which  occur  at  pul)erty  are  perhaps  more  fre- 
quently lesions  of  size  or  quantity  from  arrest  of  growth  than 
lesions  of  form  from  arrest  of  develo]^ment.  Daring  secondary 
development  the  infantile  uterus  is  transformed  into  that  of  the 
adult  chiefly  by  the  increase  in  the  size  of  the  body  and  fundus, 
and  the  dipping  down  of  the  cervix  into  the  vagina.  When  these 
changes  do  not  take  place  properly,  especially  if  the  invagination 
of  the  cervix  is  arrested,  the  uterus  becomes  flexed  upon  itself. 
Other  causes  of  this  malformation  there  are  which  will  be  again  re- 
ferred to. 

Anteflexion  of  the  uterus  is  usually  a  congenital  deformity, 
caused  by  arrest  of  development  occuri-ing  during  the  later  stage& 
of  that  process.     It  is  inferred  from  the  clinical  history  of  flexion 


FLEXIONS   OF   THE   UTERUS. 


57 


that  it  is  congenital,  but  this  is  not  perhaps  strictly  true  of  all  the 
cases  that  occur  as  primary  lesions.  I  presume  that  most  frequently 
the  malformation  takes  place  during  secondary  development  at 
puberty.  Occasionally  it  comes  from  some  pre-existing  disease,  in- 
flammatory or  degenerative,  which  weakens  the  walls  of  the  uterus 
at  the  junction  of  tiie  body  and  cervix  and  permits  it  to  become 
bent  upon  itself.  Retroflexion  often,  perhaps  generally,  is  devel- 
oped from  retroversion,  the  one  holding  a  causative  relation  to  the 
other,  but  this  form  of  acquired  flexion  will  most  conveniently 
come  uiider  the  head  of  retroversion  and  its  complications. 

Clinically  considered  in  relation  to  causation  there  are  two  classes : 
the  congenital,  called  so  because  it  is  usually  first  recognized  at  pu- 
berty ;  and  acquired,  because  it  generally  appears  after  puberty  and 
follows  some  previous  uterine  disease  either  inflammatory,  or  a  mal- 
nutrition which  reduces  the  quantity  of  tissue  at  a  given  point,  and 
permits  the  uterus  to  bend  upon  itseK.  Flexions  from  these  two 
causes  constitute  a  class  by  themselves,  and  therefore  they  alone 
will  be  treated  of  in  this  connection.  Flexions  occur  in  connection 
with  other  affections,  such  as  adhesions  of  the  body  of  the  uterus  to 
other  pelvic  organs ;  tumors  in  the  walls  of  the  uterus,  which,  by 
their  weight,  bend  the  uterus  upon  itself ;  and  pressure  from  ab- 
dominal tumors  which  crowd  the  uterine  body  out  of  place ;  but 
flexion  in  such  cases  is  only  a  complication  of  the  affection  which 
causes  it,  and  does  not  belong 
to  the  subject  of  flexion  as  a 
primary  lesion.  Theoretically, 
the  uterus  might  become 
flexed  in  either  direction ; 
but  practically  the  forward 
and  backward,  anteflexion  and 
retroflexion,  are  the  only  two 
forms  that  occur  as  uncom- 
phcated  affections.  The  later- 
al flexions  are,  as  a  rule,  sec- 
ondary to  the  diseases  already 
mentioned. 

Anteflexion,  which  occurs 
as  the  result  of  imperfect  de- 
velopment, and  which  is  oc- 
casionally acquired  from  mal- 
nutrition, is  by  far  the  most  common.  There  are  three  varie- 
ties of   anteflexion :    First,  anteflexion  of   the   cervix   (Fig.    34a) ; 


Fig.  3-la. — First  variety ;  anteflexion  of 
cervix. 


58 


DISEASES  OF  WOMEN. 


second,    anteflexion    of    the    body    (Fig.    35) ;    and,    third,    ante- 
flexion of  both  body  and  cervix  (Fig.  36). 

Pathology.  —  Flexion  of 
any  form  necessitates  some 
defect  in  the  structure  of 
the  uterus.  This  constitutes 
one  of  the  essential  differ- 
ences between  flexion  and 
version,  which  latter  is  sim- 
ply an  error  of  location 
without,  necessarily,  any 
change  of  structure  of  the 
uterus.  The  flexion  is  usu- 
ally at  the  junction  of  the 
body  and  cervix,  the  point 
corresponding  to  the  inter- 
nal OS.  Flexion  at  any  point 
in  the  body  or  cervix  oc- 
curs only  as  an  exception, 
At  the  point  of  flexion  the 
On  the  side  to  which 
On 


Fig.  '■'>'■). — Seconi 


variety  ;  anteflexion  of  body 
of  uterus. 


which  need   not  be  noticed   here, 
tissues  of  the  uterine  walls  are  deficient 
the  organ   is   bent   the  wall   is  com])ressed   and   attenuated 
the  other  side  the  loss  of  tissue  is  not  so  marked,  the  thickness 
being  but  slightly  diminished 
by  the   stretching.     The   sub- 
mucous,   fibrous    stratum    of 
tissue,  which  is  said  to   give 
firmness   and   support   to   the 
organ,  is  absent  or  deficient  on 
the  side  to  which  the  uterus  is 
bent. 

The  effect  of  flexion  on  the 
uterine  canal  is  to  produce 
constriction  or  occlusion  of 
the  internal  os.  The  external 
OS  is  sometimes  more  open 
than  in  health,  owing  to  trac- 
tion being  made  on  the  pos- 
terior lip.  The  stricture  thus 
formed  gives  rise  to  accumu- 
lation of  the  secretions  of  the  uterine  cavity,  and  to  partial  retention 
of  the  menstrual  i)roducts.     The  circulation  in  the  uterus,  as  will  be 


Fig.  \'^\. — Tliiril  varici y  ;   antctUwiuii  of  body 
and  cervix. 


FLEXIONS  OF   THE   UTERUS.  59 

readily  understood,  is  interfered  witli.  Tlie  obstruction  tends  to  keep 
up  congestion,  and  this  may  eventually  lead  to  oedema  and  a  predis- 
position to  endometritis. 

The  menstrual  fluid,  in  place  of  escaping  passively,  is  expelled, 
perhaps,  by  spasmodic  contractions.  The  submucous  stratum  of 
fibrous  tissue  is  in  some  cases  abnormally  dense  aiid  resists  the  swell- 
ing of  physiological  congestion  and  this  causes  pain.  These  patho- 
logical conditions  increase  with  time.  The  pressure  at  the  point 
of  flexion  produces  anaemia  and  atrophy  of  that  part,  and  the 
intrinsic  support  of  the  uterus  being  thus  diminished  the  flexion 
increases.  Hence,  anteflexion  of  the  flrst  two  varieties  often  pro- 
gresses to  the  third. 

The  anatomical  appearances  in  flexion  are  well  described  in  ISTie- 
meyer's  '"  Text-Book  of  Practical  Medicine."  I  quote  that  portion 
which  applies  to  anteflexion  of  the  body  of  the  uterus  :  "  On  autopsy, 
flexion  of  the  uterus  may  be  readily  recognized,  as  part  of  the  pos- 
terior wall  of  the  body,  instead  of  the  fundus,  forms  the  highest  part 
of  the  uterus.  Generally,  we  may  restore  the  sunken  fundus  to  its 
position,  but  it  sinks  back  again  to  its  former  place  when  we  let  go 
of  it.  If  we  remove  the  uterus  from  the  body,  and  hold  it  erect  by 
the  vaginal  portion,  the  fundus  sinks  down  anteriorly  ;  if  it  be  held 
horizontally,  it  not  infrequently  holds  its  weight  if  the  flexed  side 
be  upward,  but  it  bends  together  if  we  reverse  it."  To  this  I  would 
add  that  in  the  first  variety  the  cervix  projects  into  the  vagina  much 
farther  on  the  posterior  wall  than  on  the  anterior  ;  indeed,  in  marked 
cases,  the  anterior  lip  of  the  cervix  uteri  is  very  little  below  a  line 
corresponding  to  the  point  of  union  between  the  cervix  and  the  an- 
terior vaginal  wall. 

Natural  History  of  Anteflexion. — Symptomatology. — Derangement 
of  uterine  Junction  constitutes  the  principal  point  in  the  natural  his- 
tory of  flexion.  Menstiiiation,  from  its  first  establishment,  is  often 
painful — there  is  dysmenorrhoea.  The  severity  of  the  pain  bears 
some  relation  to  the  extent  of  flexion.  The  greater  the  deformity 
the  more  marked  is  the  pain,  though  there  are  exceptions  to  this  rule. 
The  character  of  the  pain  is  of  the  greatest  importance.  It  is  inter- 
mittent, and  always  precedes  the  flow.  When  the  flow  begins,  the 
pain  either  subsides  or  becomes  much  less.  The  pain  closely  resem- 
bles that  which  occurs  in  abortion  in  the  early  months  of  pregnancy. 
The  reason,  I  presume,  is  that  while  the  fluid  is  accumulating  in  the 
uterine  cavity,  pain  is  excited  by  distention ;  but  the  flow  when 
once  started,  continues  with  less  expulsive  eftbrt.  Painful  men- 
struation often  occurs  without  flexion,  but  in  such  cases  the  piain 


60  DISEASES   OF  WOMEN. 

continues  throughout  the  whole  period,  or  during  the  early  part  of 
it,  and  is  not  relieved  by  dilatation  of  the  cervix ;  while  in  flexion 
it  precedes  the  flow,  and  is  relieved  temporarily  by  dilatation.  This 
pain,  at  the  commencement  of  menstruation,  is  the  most  prominent 
symptom  in  the  history  of  flexion  as  it  occurs  in  the  young  girl.  The 
trouble  tends  to  increase  gradually.  If  the  patient  gets  married,  all 
the  symptoms  usually  increase.  Should  she  become  pregnant,  there 
is  great  liability  to  miscarriage  during  the  early  months.  The  effect 
of  the  pregnancy,  however,  in  part  at  least,  is  to  remove  the  deform- 
ity, even  wlien  miscarriage  occurs,  so  that  pregnancy  is  likely  to  occur 
again,  and  go  on  to  full  time,  and  the  deformity  is  cured  completely. 
Checking  the  menses  by  exposure  to  cold,  or  any  cause  which  will 
produce  hypersemia  of  the  uterus,  or  endometritis,  promptly  increases 
the  dysmenorrhoea,  and  gives  rise  to  new  symptoms.  Leucorrhoea, 
backaclie,  local  tenderness,  deranged  digestion,  and  nervous  disturb- 
ances, are  all  added  to  the  original  symptoms.  Sometimes  in  ante- 
flexion frequent  micturition  is  a  marked  symptom. 

There  are  all  varieties  and  degrees  of  prominence  of  the  symp- 
toms in  the  natural  history  of  flexion.  The  dysmenorrhoea  which 
begins  at  puberty  may  continue,  and  increase  but  little  through  life. 
This  is  most  likely  to  be  the  case  if  the  individual  remains  unmar- 
ried, and  can  avoid  all  the  conditions  which  tend  to  aggravate  uter- 
ine disease.  On  the  other  hand,  the  dysmenorrhoea  may  increase  in 
severity  during  each  succeeding  menstruation,  and  after  marriage 
become  intolerable.  In  the  intervals  between  the  menstrual  periods 
the  patient  in  her  early  life  is  free  from  trouble,  but  eventually 
symptoms  of  uterine  and  vaginal  inflammation  are  manifested. 
Constitutional  derangements,  especially  of  the  nervous  system,  fol- 
low, and  in  time  we  have  the  broken-down,  miserable  patients,  famil- 
iar to  all  practitioners.  Such  patients  often  seek  relief  in  the  use  of 
stimulants  and  opium,  which  only  soothe  for  a  time,  but  eventually 
aid  in  undermining  the  health  and  strength  of  the  unfortunate  suf- 
ferers. 

Owing  to  the  fact  that  all  imperfectly  developed  organs  are  less 
able  to  resist  the  causes  of  disease,  the  subjects  of  flexion  are  very 
liable  to  pelvic  peritonitis  and  diseases  of  the  ovaries  and  Fallopian 
tubes,  with  all  the  suffering  which  these  affections  give  rise  to. 

Physical  Signs. — Although  the  history  alone  might  lead  one 
with  a  tolerable  degree  of  certainty  to  suspect  the  presence  of  flex- 
ion, the  physical  signs  must  be  depended  upon  for  an  accurate  diag- 
nosis. The  physical  signs  of  flexion  arise  from  the  changed  relations 
of  the  body  and  cervix  to  each  other.     These  signs  are  detected  by 


FLEXIONS  OF  THE   UTERUS.  61 

the  touch  and  the  uterine  probe.  The  touch  may  indicate  that  the 
cervix  is  in  its  normal  position,  or  is  anteflexed,  the  os  pointing 
toward  the  introitus  in  the  same  way  that  we  find  it  in  retroversion. 
The  vaginal  portion  of  the  anterior  wall  of  the  cervix  is  much 
shorter  than  the  posterior.  Carrying  the  finger  along  the  anterior 
vaginal  wall,  the  body  of  the  uterus  can  usually  be  felt  bending  for- 
ward. The  bimanual  examination  reveals  the  deformed  condition 
of  the  uterus  in  lean  patients,  whose  abdominal  parietes  are  yield- 
ing ;  but  in  fleshy  subjects  with  rigid  abdominal  muscles,  very  little 
can  be  learned  by  this  mode  of  exploration.  When  rigidity  of  the 
parts  is  the  obstacle  to  exploration,  an  ansesthetic  may  be  used  with 
great  advantage,  as  practiced  by  Sir  J.  Y.  Simpson. 

When  the  signs  thus  obtained  point  to  flexion,  the  diagnosis 
should  be  confirmed  by  using  the  sound.  Much  trouble  is  often 
experienced  in  introducing  this  instrument.  Indeed,  it  is  impossi- 
ble in  extreme  flexion  to  carry  the  sound  into  the  uterus  without 
first  straightening  the  bend  at  the  junction  of  the  body  and  cervix. 
To  do  this,  the  cervix  should  be  seized  by  a  tenaculum,  and  gently 
drawn  downward,  while  at  the  same  time  the  fundus  is  pressed  up- 
ward and  backward  with  a  probang.  In  this  way  the  canal  is  par- 
tially straightened,  and  the  sound  can  be  introduced.  There  are 
cases  where  it  is  only  necessary  to  curve  the  sound  properly  and 
manipulate  with  care,  and  the  point  of  flexion  can  readily  be  passed. 
When  the  sound  passes  into  the  body  of  the  uterus  in  the  direction 
indicated  by  the  touch,  the  diagnosis  is  complete.  While  there  are 
many  conditions  which  might  present  the  signs  of  flexion  as  obtained 
by  the  touch,  the  combined  testimony  of  the  touch  and  sound  are 
sufficient  to  make  the  diagnosis  sure. 

Causation. — There  are  several  causes  of  flexion,  and  this  may 
account  for  the  different  opinions  held  by  authors  on  this  subject. 
The  errors,  I  presume,  come  from  investigators  accepting  the  cause 
found  in  a  limited  number  of  instances  as  applying  to  all  cases  of 
flexion.  Some  of  the  more  important  causes  assigned  may  be  briefly 
noticed. 

Rokitansky  considered  that  the  peculiar  density  and  arrange- 
ment of  the  mucous  membrane  of  the  cervix  and  lower  part  of  the 
corpus  uteri  formed  one  of  the  chief  supports  of  the  organ,  and  gave 
it  its  slight  anterior  inclination  ;  consequently,  he  looked  upon  the 
pathological  state  of  this  layer  as  the  basis  in  the  development  of 
uterine  flexions.  He  thought  the  uterus  bent  upon  itself,  from  cir- 
cumscribed atrophy  of  one  of  its  walls,  arising  from  inflammation. 
He  claimed  that  the  glands  of  the  mucous  membrane,  becoming  dis- 


62  DISEASES   OF  WOMEN. 

tended  from  imprisoned  secretions,  so  pressed  upon  the  other  tissues 
as  to  cause  atrophy  at  that  part.  When  the  distended  glands  rupt- 
ured and  collapsed,  the  part  rendered  thus  defective  permitted  the 
uterus  to  bend  upon  itself.  Several  eminent  writers  on  this  subject, 
Dr.  Ludwig  Joseph  being  the  most  recent,  after  careful  observa- 
tions, have  been  unable  to  discover  this  peculiar  condition  of  the 
mucous  membrane  and  its  submucous  layer  to  which  Rokitansky 
alludes.  If  they  are  correct,  further  discussion  of  this  supposed 
cause  is  useless.  Should  Rokitansky  be  right,  the  cause  he  favors 
would  chiefly  aifect  cases  of  acquired  flexion ;  while  the  majority  of 
cases  occur  before  we  have  any  evidence  that  inflammation  pre- 
ceded it. 

Virchow  attributes  the  primary  cause  of  flexion  to  congenital 
shortness  of  the  anterior  uterine  ligaments,  which  drag  the  body  of 
the  uterus  forward,  or  flex  it.  The  uterus  being  held  in  this  posi- 
tion, pressure  results,  which  leads  to  atrophy  of  the  tissues,  and  thus 
all  the  conditions  of  flexion  are  present. 

Klob,  who  is  one  of  the  best  authorities  on  uterine  pathology, 
doubts  the  views  expressed  by  Yirchow,  and  states  that  with  the  nor- 
mal flrmness  of  the  tissues  the  uterus  is  not  likely  to  be  deflected  by 
the  cause  in  question.  He  also  calls  attention,  as  a  reason  against  the 
theory  of  Yirchow,  to  the  fact  that  false  membranes  or  short  liga- 
ments, which  would  incline  and  fix  the  fundus  forward,  would  ne- 
cessarily cause  pressure  on  the  fundus  of  the  bladder.  This  would 
cause  the  bladder  to  distend  more  in  its  lowest  portion,  which  would 
press  the  lower  part  of  the  cervix  uteri  backward,  and  in  place  of 
producing  flexion  would  cause  anteversion.  Klob  admits  that  the 
cause  assigned  by  Yirchow  may  produce  or  maintain  flexion,  but 
only  when  there  is  defect  of  tissue  in  the  uterus  itself,  arising  from 
some  preceding  cause. 

The  relation  of  the  bladder  to  the  uterus  is  looked  on  by  some 
writers,  including  Yirchow  and  Ludwig  Joseph,  as  of  some  impor- 
tance in  the  etiology  of  flexion.  The  uterus  is  known  to  make  a 
descent  corresponding  to  the  variations  in  the  shape  of  the  bladder, 
which  in  fcetal  and  infant  life  changes  from  the  elongated  fusiform 
to  the  short  ovoid  shape,  and  its  fundus,  thus  approaching  the  floor 
of  the  pelvis,  draws  the  attached  uterus  with  it.  As  the  cervix 
uteri  is  closely  attached  to  the  posterior  surface  of  the  bladder,  it 
will  be  readily  understood  that  perverted  development  in  the  con- 
nections of  the  two  organs  might  lead  to  flexion. 

The  only  causes  which  I  consider  worthy  of  discussion  in  con- 
nection with  anteflexion,  when  it  occurs  as  a  primary  or  uncompli- 


FLEXIONS   OF   THE    UTERUS.  (53 

cated  disease,  are :  1.  Malformation  resulting  from  arrested  or  im- 
perfect development.  Flexion  arising  from  this  cause  may  be  classed 
among  the  congenital  deformities.  2.  Deformities  arising  from  in- 
flammation and  degeneration  of  the  uterine  walls  on  one  side.  This 
will  include  atrophy  of  the  anterior  uterine  wall  at  the  os  internum 
from  inflammation  and  distention  of  the  cervical  glands ;  also  fatty 
degeneration  in  advanced  life,  and  excessive  involution  after  parturi- 
tion, by  which  one  of  the  uterine  walls  is  weakened  at  the  junction 
of  the  cervix  and  body.     These  may  be  called  acquired  flexions. 

I  purposely  omit  a  number  of  conditions  usually  given  as  causes 
of  flexions,  such  as  metritis,  enlargement  of  the  corpus  uteri,  preg- 
nancy, uterine  tumors,  abdominal  tumors,  accumulations  of  fluid  in 
utero,  ascites,  fecal  accumulations,  and  adhesions  from  inflammatory 
exudations.  Several  of  these  causes,  such  as  pregnancy,  produce 
flexion  so  very  seldom  that  they  may  be  treated  as  exceptions  to  the 
ordinary  laws  of  jjathology,  and  are  of  no  practical  importance.  The 
others  named  are  more  important  than  the  flexions  which  they  pro- 
duce, and  I  should  prefer  to  discuss  flexion  occurring  under  such 
circumstances  as  a  complication  of  the  prunary  affection.  It  is,  to 
say  the  least  of  it,  objectionable  classification,  to  discuss  the  primary 
and  most  important  disease  as  the  cause  of  a  consecutive  affection, 
and  one  which  does  not  always  follow. 

Regarding  the  first  cause— imperfect  development — I  can  readily 
see  how  flexion  might  occur  therefrom.  During  the  time  when  in- 
vagination of  the  lower  portion  of  the  cervix  and  upper  part  of  the 
vagina  takes  place,  the  process  is  liable  to  progress  farther  on  one 
side  than  on  the  other.  Should  the  posterior  vaginal  wall  become 
reflected  much  higher  than  the  anterior,  the  attachment  of  the  vagi- 
na, being  lower  on  the  anterior  surface  of  the  cervix,  would  naturally 
pull  it  forward.  From  the  fact  that  this  malformation  at  the  junc- 
tion of  the  uterus  and  vagina  is  present  in  the  vast  majority  of  cases 
of  anteflexion  of  the  cervix,  I  have  looked  upon  it  as  one  important 
cause.  If  this  arrangement  should  tend,  as  it  probably  does,  to  bring 
the  cervix  forward  so  as  to  flex  the  uterus  to  a  slight  degree  previ- 
ous to  its  complete  development,  the  pressure  at  the  point  of  flex- 
ion would  arrest  the  growth  at  that  point,  and  then  the  wall  would 
become  more  attenuated  still,  and  flexion  of  the  body  would  be 
produced. 

Imperfect  development  may  cause  flexion  in  another  way. 
The  infantile  uterus,  having  little  strength  of  tissue  to  support  itself, 
might  readily  become  flexed,  and  so  remain  during  the  period  of 
secondary  development.     I  am  aware  that  good  authorities,  such  as 


€4  DISEASES   OF    WOMEN. 

Klob,  state  that  previous  to  puberty  the  uterus  is  neither  bent  back- 
ward nor  forward ;  but  other  observers  have  found  the  infantile 
uterus  anteflexed  in  many  cases,  and  one  can  readily  understand  why 
the  organ  might  remain  so.  The  position  in  sitting  at  school  and  in 
sewing  so  often  maintained  by  girls,  constipation,  and  improper  cloth- 
ing, all  tend  to  retard  development  and  hence  produce  flexion.  The 
uterus  might  readily  increase  in  size  at  all  parts  except  the  portion 
compressed  at  the  point  of  flexion. 

Flexion  occurs  also  from  excessive  development  of  the  cervix. 
The  unnaturally  long  cervix  pressing  upon  the  posterior  wall  of  the 
vagina  is  inclined  forward,  while  the  body  of  the  uterus  remains  in 
its  normal  axis.  This  produces  slight  flexion,  which  in  time  becomes 
greater,  on  the  principle  that  the  deformity,  once  established,  tends 
to  increase. 

When  flexion  is  caused  by  inflammation,  the  explanation  given 
by  Rokitansky  and  already  referred  to,  applies  in  some  cases  of  ac- 
quired flexion.  Irregular  involution  is  doubtless  one  of  the  causes  of 
flexion  when  it  occurs  after  confinement  or  miscarriage.  If  press- 
ure was  brought  to  bear  on  the  cervix,  fundus,  or  both,  so  as  to  favor 
flexion,  involution  might  go  on  beyond  the  normal  limits  at  the 
point  of  pressure. 

Treatment. — A  brief  review  of  the  various  plans  of  treatment 
will,  I  believe,  show  that  while  they  are  of  great  value,  and  capable 
of  giving  relief  in  many  cases,  still  it  will  be  found  that  they  do  not 
fully  equal  all  demands.  The  use  of  extra-uterine  pessaries  will  re- 
lieve some  of  the  prominent  symptoms,  but  will  not  overcome  the 
deformity.  Intra-uterine  pessaries,  while  they  sustain  the  uterus  in 
its  normal  shape,  are  objectionable  in  some  respects ;  they  are  often 
diflicult  to  introduce,  are  not  easily  held  in  position,  and  are  liable 
in  some  cases  to  cause  so  much  irritation  as  to  make  their  prolonged 
use  dangerous  to  life. 

The  surgical  methods  which  have  for  their  object  only  to  relieve 
the  symptoms  or  evil  consequences  of  flexion,  are  chiefly  dilatation 
and  division  of  one  wall  of  the  cervix.  Dilatation  is  certainly  of 
much  value,  but  the  improvement  is  often,  indeed  generally,  only 
temporary.  Division  of  one  side  of  the  cervix  answers  the  same 
purpose  as  dilatation,  and  the  effect  is  not  more  lasting.  But  neither 
of  these  modes  of  treatment  overcomes  the  deformity  altogether,  and 
seldom  permanently  cures  the  troublesome  symptoms.  The  merit 
of  dividing  the  cervical  wall  appears  to  me  to  be,  that  it  may  correct 
the  conditions  of  the  flexion  which  cause  sterility,  and  when  that  is 
accomplished,  and  pregnancy  follows,  the  development  of  the  uterus 


FLEXIONS   OF   THE   UTERUS.  65 

•during  gestation  permanently  cures  the  malformation  as  a  rule.  If 
pregnancy  does  not  follow,  the  patient  is  not  always  imj^roved,  ex- 
cept temporarily,  by  the  treatment. 

The  objects  to  be  attained  in  the  treatment  of  flexions  of  the 
uterus  are,  to  straighten  the  organ  and  to  keep  it  so  until  the  defect- 
ive portions  of  its  walls  become  developed  sufficiently  to  render  it 
self-sustaining.  Should  the  means  used  fail  to  overcome  the  de- 
formity, the  next  aim  should  be  to  relieve  the  patient  from  the  con- 
sequences of  the  flexion  by  other  means,  such  as  dilating  the  canal  of 
the  uterus,  or  dividing  the  posterior  wall  of  the  cervix  after  the 
manner  of  Sims.  The  means  to  be  used  in  the  management  of 
flexion  must  be  adapted  to  each  case,  and  hence  the  subject  resolves 
itself  into,  lirst,  the  treatment  of  flexion  of  the  cervix ;  second,  flexion 
•of  the  body  of  the  uterus  ;  and,  third,  flexion  of  both. 

It  follows,  naturally,  that  the  treatment  of  flexion  of  both  the 
body  and  cervix — i.  e.,  the  third  form  mentioned — should  include  the 
treatment  of  the  first  and  second  forms. 

The  treatment  of  flexion  is  as  follows:  When  the  vaginal  por- 
tion of  the  cervix  is  unusually  long  and  conical,  amputation  may  be 
•called  for,  and  is  often  followed  by  very  satisfactory  results.  In  the 
majority  of  cases  a  less  important  operation  will  answer.  By  clip- 
ping out  a  Y-shaped  piece  in  each  lateral  edge  of  the  os,  and  extend- 
ing upward  from  an  eighth  to  a  fourth  of  an  inch,  a  few  of  the 
circular  fibers  are  divided.  This  permits  the  longitudinal  fibers  to 
contract,  and  thus  shortens  the  vaginal  portion  of  the  cervix. 

By  far  the  most  frequent  and  important  lesion  that  occurs  in  the 
connection  of  the  uterus  and  vagina  is  the  imperfect  invagination  of 
the  anterior  wall  of  the  cervix,  which  has  been  described  under  the 
head  of  pathology.  To  overcome  this  deformity,  I  have  adopted 
the  following  plan  of  treatment :  The  patient  is  placed  on  her  left 
side,  and  Sims's  speculum  is  introduced.  The  anterior  lip  of  the 
•cervix  uteri  is  seized  with  a  tenaculum,  and  the  cervix  drawn  back- 
ward toward  the  hollow  of  the  sacrum.  This  puts  the  anterior 
column  of  the  vagina  on  the  stretch,  at  the  point  where  it  is  reflected 
on  the  cervix.  The  vaginal  wall  is  then  divided  transversely  with 
the  scissors,  about  three  fourths  of  an  inch  from  the  os  uteri,  the 
incision  being  from  a  quarter  to  three  eighths  of  an  inch  deep 
(Fig.  3Y).  The  vaginal  wall  is  dissected  up,  so  that  when  the  incised 
portion  is  put  upon  the  stretch  the  sides  will  come  together.  In 
other  words,  the  upper  and  lower  edges  of  the  incised  central  por- 
tion of  the  vaginal  wall  are  drawn  apart,  and  the  sides  brought 
together  to  flU  the  space,  so  that  the  transverse  incision  now  ap- 
6 


66 


DISEASES  OF  WOMEN. 


pears  as  a  longitudinal  one.     Sutures  are  introduced,  to  keep  the 
parts  together  till  they  unite  (Fig.  38). 


37. — (->peratiou  for  imperlect  invagination.     The  incision. 


If  the  uterus  is  slightly  below  its  normal  level,  and  inclined  to 
retroversion  (a  condition  not  uncommon  in  anteiiexion),  much  benefit 
will  be  obtained  by  introducing  a  double-lever  pessary,  largest  at  its 
posterior  extremity.     This  will  hold  up  the  uterus,  and,  by  making 


Fig.  38. — Operation  for  imperfect  invaji^ination.     Sutures  in  position. 

pressure  in  the  posterior  vaginal  eul-'l<-.sa<\  draw  the  cervix  back- 
ward, and  thus  hold  the  edges  of  the  wound  together  and  favor 
union.  The  effect  of  this  simple  and  safe  operation  is  to  bring^ 
the  anterior  wall  of  the  cervix  farther  down  into  the  vagina,  and 
permit  it  to  extend  backward  more  toward  the  axis  of  the  pel- 
vis, where  it  ought  to  \)l\  Tliis  ])Ian  of  treatment  I  have  found  to 
be  sufficient  for  the  relief  of  fiexion  of  the  cervix  uteri  in  many 
cases. 


FLEXIONS    OF   THE   UTERUS. 


The  treatment  of  flexion  of  the  body  of  the  uterus  requires  first 
that  the  organ  should  be  made  straight,   and  then  that  it  should 
be  kept  straight,  as  already  stated.     The  first  ob- 
ject can  be  accomplished  most  easily  by  the  use  P; 
of  EUiott's  uterine  adjuster  (Fig.  39).      I  am  in-  1 1 
debted  to  Dr.  T.  G.  Thomas  for  the  knowledge          j  i 
of  the  method  of  using  this  instrument.     It  is          !  '• 
similar  to  a  uterine  bougie,  with  a  round  metallic 
disk  at  its  end.     By  turning  this  disk,  the  point 
of  the  instrument  can  be  bent  forward  or  back- 
ward at  the  will  of  the  operator.     In  using  it  to 
straighten  the  flexed    uterus  the   instrument  is 
carried  forward  and  passed  into  the  uterus ;  the 
disk  at  the  end  is  then  turned  in  the  reverse  di- 
rection, and  the  Itistrument,  carrying  the  body 
of  the  uterus  with  it,  is  bent  in  the  opposite 
direction   until   the   body  and   cervix   uteri  are 
brought   into   line  with  each  other.     There  are 
certain  precautions  necessary  in  using  this  instru- 
ment to  straighten  a  flexed  uterus,  but  these  will 
be  brought  out  in  the  history  of  cases  which  fol- 
low. 

In  straightening  the  uteras  with  Elliott's  ad- 
juster it  is  useful  to  bend  the  uterine  body  back- 
ward beyond  the  line  of  the  cervix  when  this  can 
be  done  without  causing  much  pain.  The  stretch- 
ing of  the  wall  of  the  uterus  at  the  point  of  flex- 
ion stimulates  nutrition  and  gives  strength  to  the 
weak  part.  By  repeating  this  treatment  many 
times,  much  relief  is  given,  and  much  progress  I  I 

made  toward  finally  overcoming  the  defoiTaity. 

To  keep  the  uterus  straight  in  antefiexion  of 
the  body,  two  of  the  many  methods  commended 
I  have  found  useful — the  first  being  the  use  of 
a  retroversion  pessary  to  draw  the  uterus  back- 
ward, as  suggested  by  Emmet,  in  order  to  bring  the  cervix  on  a 
line  with  the  body  of  the  uterus. 

The  other  means  is  the  intra-uterine  stem  with  a  vag-inal 
pessary  to  keep  it  in  position  ;  the  glass  or  hard-rubber  stem  and 
a  closed  ring  pessary  of  soft  rubber  answers  very  well  (see 
Fig.  40). 

In  using  the  intra-uterine  stem  the  greatest  possible  care  should 


Fig.  39.— Elliott's  uter- 
ine  adjuster. 


68  DISEASES   OF   WOMEN. 

be  employed  because  of  the  great  danger  of  exciting  inflammation. 
Before  resorting  to  the  use  of  this  instrmnent  all  congestion  and 
irritability  should  be  subdued  as  far  as  possible,  and  the  uterus 
should  be  trained  to  tolerate  a  foreign  body  in  its  cavity.  To 
accomplish  this,  all  the  ordinary  means  for  the  relief  of  metritis 
should  be  employed.  Cocaine,  which  has  proved  to  be  of  great 
value  in  other  departments  of  surgery,  is  a  great  help  to  the  gynae- 
cologist, especially  in  the  management  of  the  class  of  cases  now  under 
consideration.  By  the  use  of  this  agent  the  extreme  hyperaesthesia, 
which  renders  the  use  of  the  sound  not  only  painful  but  dangerous, 
can  be  completely  overcome.  When  I  first  began  to  use  cocaine 
I  was  fearful  that,  while  the  sound  or  adjuster  could  be  used  without 
pain  under  the  effects  of  this  local  aiuEsthetic,  there  might  be  as 
much  danger  of  causing  inflammation  as  there  would  be  without  it ; 
but  experience  has  proved  that  my  fears  were  groundless.  I  prefer 
a  two-per-cent  solution,  and  depend  upon  repeated  applications  to 
produce  the  desired  effect.  This  is  a  safe  way  of  using  cocaine.  At 
the  time  of  using  the  solution  it  should  be  at  about  the  temperature 
of  the  body,  and  it  should  be  introduced  with  a  pipette.  I  apply 
it  to  the  canal  of  the  cervix  and  os  internum,  and  in  a  few  minutes 
pass  the  sound  just  beyond  the  internal  os.  If  this  causes  much  pain, 
I  make  another  application  and  try  the  sound  again ;  and  if  it  can  be 
easily  introduced,  I  permit  it  to  remain  in  the  canal  for  a  minute  or 
two. 

At  the  next  treatment  I  repeat  the  application  and  use  a  larger 
sound,  and,  if  this  is  well  tolerated,  I  pass  the  pipette  into  the  cavity 
of  the  body  and  apply  the  cocaine.  If  that  causes  no  pain,  I  use  the 
Elliott  adjuster  and  straighten  the  uterus,  if  I  can  do  so  without 
causing  suffering.  At  each  subsequent  use  of  the  adjuster  I  apply 
cocaine  until  the  tenderness  disappears.  Then  the  cocaine  is  omit- 
ted, and  if  the  sensitiveness  does  not  return  I  feel  sure  that  the  stem 
pessary  will  be  tolerated. 

I  am  inclined  to  think  that  cocaine  aids  in  relieving  inflannna- 
tion.  Its  immediate  effect  is  to  reliev'e  congestion,  and  although 
the  hypersemia  returns  after  the  effect  passes  off,  I  do  not  believe 
that  it  does  so  to  the  original  extent. 

Defects  of  the  canal  of  the  uterus  are  frequently  associated  with 
flexion.  In  some  cases  the  whole  canal  of  the  cervix  is  too  nar- 
row, and  in  others  there  is  a  stricture  at  the  internal  os.  To  over- 
come these  defects,  and  to  aid  in  correcting  the  flexion,  several 
methods  have  been  employed,  tlie  chief  among  them  being  incision 
and  dilatation.    When  the  constriction  is  at  the  external  os  uteri, 


FLEXIONS   OF  THE   UTERUS. 


69 


Fig.  40. — Glass  stem,  with 
soft  rubber  base. 


I  prefer  incision  followed  hy  dilatation,  easy  and  gradual,  or  forci- 
ble. The  first  consists  in  passing  graduated  sounds,  the  other  in 
using  the  uterine  dilator  (see  Fig.  16). 

I  prefer  the  forcible  dilatation  when  there  are  no  contra-indica- 
tions,  such  as  extreme  sensitiveness;  but  I  do  not  approve  of  carry- 
ing the  dilatation  beyond  that  which  is  sufficient  to  admit  a  No.  12 
or  16  English  sound.  The  extreme  dilatation  practiced  by  some, 
which  is  carried  to  a  point  sufficient  to  ad- 
mit the  index-finger,  is  dangerous  and  un- 
necessary. In  cases  complicated  with  endo- 
metritis, adenoma,  or  stenosis  at  the  internal 
OS,  I  employ  free  dilatation,  curetting,  and 
packing  with  gauze.  This  treatment  has 
been  successful  in  so  many  cases  that  I  now 
give  it  first  place.  If  the  flexion  returns  after 
this  the  stem  pessary  can  be  employed.  A 
fuller  account  of  this  is  given  in  the  treat- 
ment of  corporeal  endometritis. 

Finally,  it  may  be  noted  that  success  in 
the  treatment  of  flexions  depends  upon  the 
careful  use  of  the  means  suggested,  avoiding, 

as  far  as  possible,  the  ever-present  danger  of  exciting  inflammation, 
which  may  make  matters  far  worse.  And  much  depends  upon  the 
age  of  the  patient.  It  is  always  more  easy  to  correct  deformities 
in  the  young  than  in  those  of  more  advanced  life.  It  should  also  be 
borne  in  mind  that  there  is  a  tendency  for  the  flexion  and  all  con- 
sequent symptoms  to  return  unless  utero-gestation  follows.  On  this 
account  I  have  classifled  the  results  of  my  treatment  in  married 
women  under  two  heads,  viz.,  relieved,  and  cured.  The  former  em- 
braces those  who  have  been  relieved  from  dysmenorrhoea,  but  have 
remained  sterile,  and  the  latter  those  who  have  been  relieved  and  have 
borne  children. 

Ninety  per  cent  have  been  relieved  or  cured  of  dysmenorrhcea, 
and  about  fifty  per  cent  cured  of  sterility.  Comparing  my  results 
with  those  of  other  gynecologists,  I  have  reason  to  be  quite  in  favor 
of  the  treatment  that  I  have  employed.  Sims's  operation — that  is, 
dividing  the  cervical  wall  posteriorly  and  keeping  it  open — was  the 
treatment  of  anteflexion  years  ago,  and  I  followed  that  practice 
for  a  long  time,  but  abandoned  it  in  favor  of  the  methods  given 
above.  Hearing  very  little  about  it  now  and  for  ten  years  past,  I 
presume  that  it  has  fallen  into  disuse. 

About  seven  years  ago  Professor  E.  C.  Dudley,  of  Chicago,  in- 


70  DISEASES  OF   WOMEN. 

troduced  to  the  profession  a  modification  of  Sims's  operation  that 
found  favor  with  many.  The  doctor's  description  of  his  operation 
is  as  follows : 

"  Under  ether  the  uterus  is  exposed  by  Sims's  speculum.  The 
uterine  canal  is  dilated  by  means  of  Palmers  or  a  light  Ellinger's 
dilator  sufficiently  to  permit  the  introduction  of  a  dull  spoon 
curette.  The  object  of  the  curettement  is  to  remove  any  granula- 
tions that  may  give  rise  to  hypersecretion  or  menorrhagia. 

"  The  endometrium  is  then  thoroughly  irrigated  with  hot  ster- 
ilized water.  Then  the  cervix  is  divided  backward  in  the  median 
line  considerably  past  the  utero-vaginal  attachment.  The  cut  sur- 
faces are  held  apart  by  means  of  two  tenacula — one  in  the  hand  of 
the  operator  and  the  other  in  the  hand  of  an  assistant — while  the 
incision  is  somewhat  deepened  by  means  of  a  scalpel,  especially  on 
the  side  of  the  cervical  canal. 

"  On  each  side  the  surface  thus  incised  is  now  folded  upon  itself 
and  secured  by  silkworm-gut  sutures.  These  sutures  are  not  intro- 
duced in  such  a  manner  as  to  stitch  the  intra-cervical  to  the  vaginal 
margin  of  the  cut  surface,  but  the  cut  surface  is  folded  upon  itself 
in  a  direction  at  right  angles  to  this — i.  e.,  on  either  side  of  that 
point  at  the  margin  of  the  os  externum  where  the  backward  incision 
is  commenced — and  is  stitched  to  the  very  angle  of  the  incision  so 
that  the  cut  surface  is  folded  upon  itself,  not  from  within  outward, 
but  from  before  backward.  Thereby  the  os  externum  is  carried 
directly  back  to  the  angle  of  the  incision. 

"  Already  the  cervix  has  commenced  to  point  backward  in  its 
normal  direction  toward  the  hollow  of  the  sacrum,  instead  of  foi-- 
ward  toward  the  vaginal  outlet.  Then  the  anterior  lip  of  the  cervix 
is  caught  with  a  tenaculum  and  partially  removed. 

"■  This  incision  should  extend  to  the  os  externum,  but  not 
into  it. 

"  Sutnres  are  used  for  the  purpose  of  folding  the  exposed  sur- 
face upon  itself  from  side  to  side.  The  removal  of  a  portion  of  the 
anterior  lip  is  not  only  not  a  mutilation,  but  it  may  even  correct  a 
deformity,  because  in  antefiexion  the  anterior  lip  is  often  elongated 
in  consequence  of  the  relatively  greater  pressure  exerted  upon  the 
posterior  lip  by  the  posterior  vaginal  wall." 

While  I  know  that  this  o])eration  is  a  great  improvement  upon 
the  Sims  operation,  I  must  say  that  I  prefer  the  methods  of  treat- 
ment already  given. 


FLEXIONS   OP  THE  UTERUS.  71 


ILLUSTRATIVE    CASES. 


Anteflexion  of  the  Cervix  Uteri,  Sims's  Operation.  (Relieved.) — 
This  patient  was  a  strong,  healthy  lady,  who  began  to  menstruate  at 
the  age  of  fourteen  years.  She  continued  in  good  health,  and  the 
menses  were  normal,  except  that  she  had  more  discomfort  than  be- 
longs to  perfect  health.  About  the  age  of  eighteen  menstruation 
became  more  painful,  and  she  had  some  backache  and  occasional 
leucorrhoea.  These  symptoms  increased  but  little  until  she  was 
married,  at  twenty -two  years  of  age.  Then  she  began  to  have 
dysmenorrhoea,  and  occasional  menorrhagia.  The  leucorrhcea  and 
backache  became  more  persistent  and  her  strength  failed.  The 
pain  at  the  menstrual  period  was  not  very  severe ;  in  fact,  it  was 
not  at  all  like  the  violent  pain  often  present  in  flexion  of  the  body 
of  the  uterus,  but  it  made  her  life  quite  miserable  at  that  time. 
About  eighteen  months  after  her  marriage  she  first  applied  for 
treatment,  when  the  above  symptoms  were  related. 

The  OS  externum  pointed  toward  the  vulva,  and  the  vaginal  por- 
tion of  the  cervix  was  slightly  flattened  from  below  upward.  The 
invagination  of  the  cervix  anteriorly  was  nearly  normal,  but  not  in 
proportion  to  that  of  the  posterior  wall,  which  appeared  to  be  ex- 
cessive. The  body  of  the  uterus  was  in  its  normal  position  ;  the 
sound  could  not  be  passed  until  the  cervix  was  dragged  backward 
and  brought  in  a  line  with  the  body. 

She  was  treated  for  a  time  to  relieve  her  congestion  and  cervical 
endometritis,  and  then  the  posterior  wall  of  the  cervix  was  divided 
according  to  Sims's  method.  When  the  edges  of  the  wound  healed, 
there  was  considerable  inversion  of  the  mucous  membrane,  showing 
that  it  was  redundant.  The  protruding  portions  were  trimmed  off, 
and  then  tlie  results  of  the  operation  were  quite  satisfactory  in  ap- 
pearance. She  was  relieved  of  all  her  symptoms,  for  a  time  at  least, 
but  remained  sterile,  although  the  canal  was  large  enough,  and  the 
sound  could  he  passed.  Three  years  afterward  she  was  seen,  and  then 
she  was  complaining  of  leucorrhcjea  and  occasional  pelvic  pains. 

This  case  was  treated  fifteen  years  ago,  and  is  the  last  one  in 
which  I  have  performed  Sims's  operation  or  any  of  its  modifications 
for  flexion. 

Extreme  Anteflexion  of  the  Cervix  Uteri;  Dysmenorrhoea.  (Re- 
covery.)— The  patient  was  first  seen  at  the  age  of  twenty-five.  Her 
past  history  was  that  of  good  health.  Menstruation  occurred  first  at 
fifteen,  and  from  that  time  onward  was  normal,  except  that  it  was 
accompanied  with  pain.     During  the  first  few  years  after  puberty 


72  DISEASES  OF  WOMEN. 

the  pain  was  slight,  but  it  gradually  increased  until  it  was  suffi- 
ciently severe  to  unfit  her  for  everything  during  the  menstrual 
period.  Her  general  health  began  to  fail ;  she  lost  flesh,  and  became 
very  nervous  and  irritable,  and  it  was  on  this  account  that  she  sought 
relief. 

I  found  that  the  anterior  wall  of  the  cervix  uteri  was  on  a  line 
with  the  anterior  wall  of  the  vagina,  and  the  os  pointed  toward 
the  pubes.  The  posterior  wall  of  the  cervix  projected  into  the  va- 
gina far  more  than  normal ;  in  fact,  the  cervix  was 
hooked  upward.  The  body  and  fundus  were  in  the 
normal  position. 

Fig.  41  will  give  an  idea  of  this  form  of  flex- 
ion. It  gave  the  impression  that  in  the  descent  of 
the  uterus  the  anterior  wall  of  the  cervix  had  been 
arrested  in  its  progress  by  the  vaginal  wall,  while 
anteflexion*^  ^^^®  posterior  wall  of  the  uterus  descended  beyond 
the  normal  extent.  It  was  very  difficult  to  pass  the 
sound ;  to  do  so,  the  uterus  had  to  be  raised  up  in  the  pelvis  and 
partially  retroverted.  Drawing  the  cervix  forcibly  backward  toward 
the  sacrum  developed  a  band  of  the  anterior  wall,  which  ran  from 
the  extreme  end  of  the  cervix  upward  and  forward  about  an  inch 
and  a  half,  and  there  blended  with  the  vaginal  wall.  It  was  easily 
seen  that  this  abnormal  attachment  of  the  vagina  was  the  cause  of 
the  flexion  of  the  cervix. 

Preparatory  treatment  was  employed  for  a  short  time,  to  reduce 
congestion,  and  then  the  operation,  already  described,  to  correct  the 
invagination  of  the  cervix,  was  performed.  The  ridge  of  anterior 
vaginal  wall  was  divided  a  little  less  than  an  inch  from  the  cervix, 
and  then  very  gentle  traction  was  sufficient  to  draw  the  cervix  back 
into  its  proper  relations  with  the  body  of  the  uterus.  The  wound, 
which  was  made  at  right  angles  to  the  axis  of  the  vagina,  became 
parallel  to  it,  when  the  cervix  was  carried  back  into  its  normal  po- 
sition. It  was  closed  with  silk  sutures,  carried  deep  down  into  the 
wall  of  the  vagina,  to  make  sure  that  the  deeper  portions  of  the 
wound  were  coaptated.  When  the  sutures  were  tied,  the  invagina- 
tion was  seen  to  be  complete,  and  the  cervix  was  carried  well  back, 
quite  as  far  as  it  should  be;  there  was  also  a  noticeable  traction 
on  the  sutures,  because  the  cervix  inclined  to  flex  forward  again. 
To  correct  this,  a  stem-pessary  was  introduced,  which  extended  about 
half-way  up  the  cavity  of  the  body  of  the  uterus.  This  w^as  held  in 
position  at  first  with  a  marine  lint  tampon,  and  when  the  wound 
healed  the  stem  was  held  in  place  by  the  retaining  pessary.     The 


FLEXIONS  OF  THE  UTERUS.  73 

operation  was  done  witliout  ether,  and  the  patient  did  not  complain 
of  pain,  except  wlien  the  stem  was  introduced  into  the  uterus. 

Ten  dajs  after  the  operation  the  sutures  were  removed  and  the 
union  was  complete  ;  the  stem  was  still  left  in  place.  After  another 
week  had  gone,  there  was  considerable  congestion  in  the  canal,  indi- 
cated by  a  free  discharge.  The  stem  was  removed,  and  an  applica- 
tion of  tannin  and  glycerin  made.  After  the  sutures  were  removed, 
the  douche  of  borax  and  warm  water  was  used  daily,  and  once  a 
week  the  stem  was  removed  and  the  canal  painted  with  tannin  and 
glycerin.  The  next  menstrual  period  was  without  the  severe  pain 
which  she  suffered  before  the  treatment.  Still  there  were  backache 
and  pelvic  tenesmus.  The  stem  was  left  in  place  during  menstrua- 
tion and  for  three  weeks  after,  but  during  that  time  it  was  removed 
every  week,  and  the  application  of  tannin  made. 

The  second  menstruation  after  the  operation,  the  first  after  the 
removal  of  the  stem,  was  painless.  Subsequently  there  was  no  re- 
currence of  the  flexion,  and  her  menstruation  has  continued  regu- 
lar and  without  pain.  It  is  now  three  years  since  she  was  treated, 
and  she  remains  well  and  free  from  dysmenorrhoea. 

I  may  add  here,  that  in  all  cases  of  anteflexion  of  the  cervix,  due 
to  imperfect  vagination,  the  treatment  given  above  has  been  suc- 
cessful. 

Anteflexion  of  the  Body  and  Cervix  Uteri  with  Prolapsus.  (Eecov- 
ery.) — This  patient  was  a  little  below  the  medium  size,  but  was 
strono;  and  active.  She  be^an  to  menstruate  at  thirteen,  and  con- 
tinned  to  do  so  rather  irregularly.  She  generally  went  over  time  a 
varying  number  of  days.  From  the  first,  menstruation  was  painful, 
the  pain  gradually  increasing  from  month  to  month  and  year  to  year. 
This  pain  was  characteristic  of  flexion ;  it  began  before  the  flow, 
diminished  when  the  flow  was  well  established,  and  subsided  entirely 
on  the  second  day.  The  pain  was  referred  to  the  uterus,  and  was 
intermittent.  From  puberty  to  about  twenty-one  years  of  age  her 
health  was  perfect  between  the  menstrual  periods.  She  then  began 
to  sufter  from  backache,  leucorrhtea,  occasional  ovarian  pain,  and 
gradually  her  digestion  became  impaired,  and  the  nervous  system 
fretted. 

She  was  first  seen  at  the  age  of  twenty-four,  when  the  above 
history  was  obtained.  It  was  evident  that  all  her  symptoms  were 
increasing  in  severity ;  general  congestion  and  tenderness  of  the 
vagina,  uterus,  and  ovaries,  were  found  at  the  examination.  The 
OS  externum  pointed  toward  the  vulva,  and  the  fundus  could  be  felt 
through  the  anterior  wall  of  the  vagina.     The  cervix  was  normal  in 


74  DISEASES  OF  WOMEN. 

size,  and  projected  into  the  vagina  in  due  proportions,  anteriorly  and 
posteriorly.  The  uterus  rested  low  down  in  the  pelvis,  and  the  cer- 
vix appeared  to  be  bent  forward  by  the  pressure  upon  the  pelvic  floor. 
These  signs,  obtained  by  touch,  were  all  confirmed  by  the  sound 
and  speculum.  The  sound  was  passed  through  the  os  internum  with 
difficulty  at  first.  There  was  no  change  in  the  structures  of  the 
uterus  except  the  flexion ;  the  congestion  was  well  marked,  and  there 
was  slight  leucorrhcea,  indicating  that  cervical  endometritis  was 
being  developed. 

The  treatment  of  this  patient  consisted  in  remedies  to  improve 
digestion.  Bromide  of  sodium  was  given  to  quiet  her  nervous  sys- 
tem. Locally,  the  hot-water  douche  was  employed ;  the  os  exter- 
num was  dilated,  and  tincture  of  iodine  applied  to  the  cervical 
canal ;  the  uterus  was  raised  to  its  proper  elevation,  and  held  there 
at  first  wnth  a  tampon,  and  afterward  with  a  small  Peaslee's  pessary. 
The  following  week  the  internal  os  was  dilated,  until  it  admitted 
a  No.  10  sound,  and  the  iodine  was  also  repeated.  This  caused  much 
pain,  and  compelled  the  patient  to  rest  in  bed  a  few  days,  during 
which  time  the  hot  douche  was  continued.  After  this,  the  uterus 
was  made  straight  by  using  Elliott's  adjuster  once  a  week.  The 
douche  and  iodine  were  continued,  and  this  completed  the  plan  of 
treatment. 

For  six  months  this  course  of  local  treatment  was  followed  out, 
the  constitutional  treatment  being  varied  as  the  symptoms  changed. 
The  tenderness  and  congestion  first  disaj)peared,  and  the  pain  dur- 
ing menstruation  gradually  became  less  and  less,  and  finally  ceased 
entirely. 

The  patient  remained  under  observation  two  months  longer,  and 
then  married,  and  seven  months  later  her  physician  reported  to  me 
that  she  was  four  months  pregnant. 

Anteflexion  of  the  Body  of  the  Uterus ;  Stenosis  at  the  Os  Inter- 
num,  treated  with  Stem-Pessary.  (Recovery.) — This  patient  had  good 
health,  l)ut  was  of  a  highly  nervous  temperament,  a  condition  which 
had  been  increased  by  a  severe  and  prolonged  education.  She  be- 
gan to  menstruate  at  fifteen,  and  had  dysmenorrhea  from  the 
beginning.  She  managed  to  get  along  by  resting  at  the  menstrual 
periods,  and  bearing  her  sufiiering  as  best  she  could,  but  at  the  age 
of  twenty-eight  gave  up,  and  sought  advice.  Her  general  health 
at  that  time  was  impaired,  and  she  was  quite  despondent.  When 
first  examined,  the  usual  signs  of  anteflexion  of  the  body  of  the 
uterus  were  found.  The  cervix  was  also  slightly  bent  forward. 
The  canal  of  the  uterus  was  of  full  size,  except  at  the  internal  os ; 


FLEXIONS  OF  THE   UTERUS.  Y5 

a  small  probe  only  could  be  passed  at  that  j:)oint.  The  uterus  was 
quite  tender,  and  there  was  some  catarrh  of  the  cervical  mucous 
membrane.  Tonic  and  sedative  treatment  was  begun,  and  the  strict- 
ure was  incised  on  two  sides,  with  the  hysterotome. 

After  this,  a  sound  was  passed  twice  a  week  for  a  time.  The  pa- 
tient was  much  relieved  by  this  treatment,  but  still  suffered  pain  at 
the  meustraal  periods.  The  pain  returned  to  a  certain  extent,  at 
each  menstruation,  and  at  the  end  of  a  year  treatment  had  to  be  re- 


FiG.  42. — Skene's  hysterotome. 

newed.  At  that  time  the  patient  appeared  to  be  as  badly  off  as 
when  first  seen.  Dilatation  of  the  canal  and  straightening  the  uterus 
with  Elliott's  adjuster  gave  some  relief.  More  thorough  treatment 
was  advised,  but  she  would  not  consent  to  give  her  whole  time  to  it. 

Four  years  later  the  patient  returned  in  much  worse  condition 
than  when  first  treated.  The  tissues  of  the  uterus  were  much  hard- 
er, and  there  was  more  tenderness.  Great  pain  was  experienced  upon 
passing  the  sound,  and  any  effort  to  straighten  the  uterus  was  un- 
bearable. Sleeplessness  was  now  a  prominent  symptom,  and  she 
was  obliged  to  take  morphine  at  the  menstrual  periods. 

I  prescribed  the  rest-treatment,  with  tonics,  bromides,  massage, 
and  the  hot-water  douche,  and  the  application  of  tincture  of  iodine 
to  the  cervix  uteri  and  the  upper  part  of  the  vagina.  When  the 
general  health  had  been  improved  by  two  months  of  this  treatment, 
the  cervical  canal  was  dilated,  under  the  use  of  cocaine,  until  it  ad- 
mitted a  ]S"o.  12  sound.  The  uterus  was  then  straightened  with  the 
Elliott  adjuster,  and  a  glass  stem-pessary  introduced.  Although  she 
was  kept  quiet  after  the  introduction  of  the  stem,  the  suffering  was 
so  great  that  at  the  end  of  two  hours  it  had  to  be  removed.  The 
general  treatment  was  resumed  for  about  four  days,  and  the  stem 
was  again  used ;  this  time  it  was  worn  for  five  days,  but  had  to  be 
again  removed,  owing  to  the  pain  it  caused.  The  irritation  was 
again  subdued  by  the  hot  douche  and  cocaine  applied  to  the  canal  of 
the  cervix,  and  occasionally  an  application  of  iodine  and  carbolic  acid 
was  made.     A  week  later  the  stem  was  used  again ;  it  then  caused 


Y6  DISEASES  OF  WOMEN. 

less  pain,  but  she  had  to  remain  in  bed,  and  there  was  still  consid- 
erable distress.  There  was  also  a  marked  leucorrhoeal  discharge.  It 
was  necessary  to  remove  the  instrument  about  every  five  days,  and 
treat  the  cervical  endometritis. 

Three  weeks  passed  before  the  patient  could  be  trusted  to  walk 
around,  and  it  was  two  months  longer  before  she  could  walk  out  and 
nde  without  causing  pain.  The  dysmenorrhoea  was  less  severe  each 
month,  and  finally  subsided  entirely.  The  stem  was  worn  altogether 
about  four  months ;  during  all  that  time  the  case  had  to  be  watched 
and  treated  for  a  recurring  endometritis,  but  finally  tlie  recovery  was 
complete. 

Two  years  have  passed  since  the  treatment  was  completed,  and 
the  patient  remains  well.  The  chances  are,  however,  that  the  flexion 
will  recur. 

It  will  be  noticed  that  the  stem  caused  much  irritation,  and  re- 
quired constant  watching.  This  I  find  is  the  case  very  often.  There 
are  few  patients  who  will  tolerate  the  stem  unless  great  care  is  tak- 
en, and  they  are  treated  the  moment  that  symptoms  appear.  The 
longer  the  trouble  has  existed,  the  more  difiicult  it  is  to  use  the 
stem.  The  uterus  becomes  more  dense  in  structure  and  more  sensi- 
tive in  old  cases,  and  the  results  of  treatment  are  not  very  satisfac- 
tory. This  is  the  rule,  and  there  are  not  many  exceptions  to  it. 
The  patient  whose  case  I  have  just  described  is  one  of  the  oldest 
that  I  have  ever  successfully  treated  for  flexion. 

All  the  cases  here  given  are  intended  to  show  the  different  forms 
of  flexion,  and  the  various  methods  of  treatment  employed.  It  will 
be  seen  that  my  object  is  not  to  use  one  method  of  treatment  in  all 
forms,  but  to  adapt  the  treatment  to  the  peculiar  requirements  of 
each  case. 

Finally,  I  may  add  that  I  have  succeeded  in  relieving  all  cases 
of  flexion,  of  whatever  form  or  degree,  temporarily  at  least,  by  the 
treatment  described,  excepting  when  there  were  complications,  such 
as  ovarian  disease,  or  the  results  of  old  inflammations.  A  consider- 
able number  have  entirely  recovered,  and  borne  childi'en. 


CHAPTER  y. 

DISEASES    OF    THE    EXTERNAL    ORGANS    OF    GENERATION. 
ANATOMY. 

The  Pudendum. — The  pudendum,  comprises  all  those  parts  that 
are  situated  at  the  outer  and  lower  portion  of  the  pelvis.  It  is 
bounded  above  by  the  lower  part  of  the  abdomen,  on  either  side 
by  the  thighs,  and  below  by  the  perinseum.  In  general  outline  it  is 
wedge-shaped,  the  edge  being  downward. 

The  several  parts  are  the  mons  veneris,  the  labia  majora  and 
minora,  the  clitoris,  and  the  hymen. 

The  mons  veneris  is  a  mass  of  tissue  which  covers  the  sym- 
physis pubis,  and  occupies  the  triangular  space  formed  by  the  junc- 
tion of  the  abdomen  and  thighs ;  it  is  composed  of  fatty  tissue  and 
rather  thick  integument,  which,  after  puberty,  is  covered  with  hair. 
At  its  lower  border  it  is  divided  into  two  folds  by  the  upper  por- 
tion of  the  urogenital  fissure.  The  labia  majora  are  two  prominent 
rounded  folds  of  integument,  continuous  above  with  the  mons  vene- 
ris, which  extend  downward  to  the  perineeum.  They  are  formed 
by  integument  covered  with  hair  on  the  outer  side ;  the  inner  sur- 
face is  more  like  mucous  membrane  in  general  appearance,  but  it 
contains  sebaceous  glands  instead  of  mucous  follicles.  The  tissues 
of  the  labia  beneath  the  skin  are,  connective  tissue,  elastic  elements, 
and  fatty  lobules  with  underlying  adipose  structure.  The  vascular 
supply  is  abundant,  forming  a  venous  plexus. 

The  labia  minora,  also  called  the  nymphse,  are  two  small  folds  of 
mucous  membrane,  situated  upon  the  inner  sides  of  the  labia  majora, 
and  extending  downward  until  they  meet  posteriorly,  and  form  the 
thin  circular  band,  the  fourchette  or  frgenidum  vulvce,  which  extends 
across  at  the  posterior  part  of  the  opening  of  the  vagina  outside  of 
the  hymen.  The  outer  surfaces  of  the  labia  minora  are  continuous 
with  the  labia  majora,  and  the  inner  surfaces  with  the  mucous  mem- 
brane of  the  vestibule. 

77 


78 


DISEASES  OF  WOMEN. 


The  clitoris  is  analogous  to  the  penis,  but  possesses  neither  corpus 
spongiosum  nor  urethra ;  it  is  erectile  in  structure,  and  is  described 
as  having  three  parts — the  crura,  corpus,  and  glans.     The  crura  are 


:*• 


Fig.  43. — The  external  genitals  of  a  woman  who  has  borne  children. 

oblong,  spindle-shaped  processes,  formed  by  the  bifurcation  of  the 
corpus  ;  they  are  attached  to  the  rami  of  the  ischium  and  pubos.  The 
corpus  is  located  in  tlie  median  line  beneath  the  pubic  arcli,  and 
terminates  anteriorly  in  a  rounded  extremity,  the  glans. 

Tlie  relations  of  the  clitoris  and  the  labia  minora  are  as  follows: 
Each  labium  divides  anteriorly  into  two  folds,  which  surround 
the  glans  clitoridis,  the  superior  folds  meeting  to  form  the  preputium 
clitoridis  ;  the  inferior  folds  being  attached  to  the  glans,  and  forming 
the  fnemim. 

The  vestibule  is  the  triangular,  smooth  surface,  bounded  above 
by  the  clitoris,  on  either  side  by  the  nymphoe,  and  below  by  the  an- 


DISEASES   OF  THE   EXTERNAL   ORGANS  OP  GENERATION.      79 

terior  vaginal  wall.  Jast  above  the  junction  of  the  vestibule  and 
vagina  the  meatus  urinarius  is  situated.  It  is  distinguished  by  its 
projection  beyond  the  general  surface  of  the  vestibule.  The  hymen, 
is  a  thin  semi-lunar  fold  covered  on  both  external  and  internal  sur- 
faces with  mucous  membrane,  and  stretches  across  the  posterior  part 
of  the  orifice  of  the  vagina.  It  is  a  continuation  of  the  vagina 
(Budin).  In  fact,  the  hymen  covers  the  orifice  of  the  vagina,  closing 
it  completely,  except  a  small,  crescentic  opening  just  below  the  mea- 
tus urinarius.  It  varies  in  different  subjects  in  regard  to  its  shape, 
hence  the  above  description  can  only  be  taken  as  that  of  the  typical 
form — the  deviations  from  this  type  will  be  referred  to  in  connec- 
tion with  the  pathological  conditions  of  the  hymen. 

The  meatus  urinarius  is  situated  in  the  median  line,  at  the  junc- 
tion of  the  lower  margin  of  the  vestibule  and  the  margin  of  the  an- 
terior wall,  about  three  quarters  of  an  inch  below  the  clitoris.  It  is 
kept  closed  by  the  muscular  tissue  of  the  urethra,  and  presents  a 
puckered  appearance  and  projects  slightly  beyond  the  general  plane 
of  the  vestibule. 

The  line  of  junction  between  skin  and  mucous  membrane  runs 
along  the  base  of  the  inner  aspect  of  the  labium  majus,  passes  down 
beside  the  base  of  the  outer  as23ect  of  the  hymen,  and  through  the 
fossa  navicularis. 

The  deeper  structures  of  the  external  parts  of  generation  are 
mostly  glands  and  blood-vessels  with  connective  tissue — the  arrange- 
ment of  the  two  latter  giving  the  characteristics  of  erectile  tissue. 

The  glands  are  of  two  kinds,  the  sebaceous  and  mucous.  The 
sebaceous  glands  are  abundant  in  the  tissues  of  the  nymphse ;  they 
furnish  a  yellowish-white  secretion,  which  has  a  peculiar  odor.  In 
those  who  are  not  quite  cleanly  in  their  habits  this  secretion  accumu- 
lates beneath  the  upper  folds  of  the  nymphse,  around  the  glans  cli- 
toridis. 

The  mucous  glands  are  of  two  varieties — the  glandul?e  vestibu- 
lares  majores  and  the  gland ulae  vestibulares  minores. 

The  glandulge  vestibulares  minores  are  about  six  in  number,  and 
are  situated  about  the  meatus  urinarius ;  they  are  of  the  compound 
racemose  variety,  and  have  short  ducts  with  large  orifices.  Some- 
times one  or  more  of  these  ducts  is  found,  much  enlarged,  and  look- 
ing like  a  cul-de-sac,  large  enough  to  admit  the  point  of  a  small 
catheter. 

The  glandule  vestibulares  majores  are  two  in  number  and  about 
the  size  of  a  pea,  and  are  of  a  reddish-yellow  color.  They  are  situ- 
ated at  the  posterior  extremity  of  the  buibi  vestibuli,  and  are  par- 


80 


DISEASES  OF   WOMEN. 


tially  included  in  the  bulhi,  or,  more  properly  speaking,  the  glands 
and  the  bulbi  overlap  each  other. 

They,  like  the  glandulse  minores,  are  of  the  compound  racemose 
variety,  and  their  acini  open  into  a  duct,  more  than  half  an  inch  in 
length,  which  is  wide  where  it  leaves  the  gland,  but  becomes  nar- 


YiG.  44. — The  superficial  veins  of  the  perinaMim  (Savajjc);  c,  corpus  clitoridis ;  1,  2,  3, 
corpus  cavernosum  urethra; ;  5,  anterior  supcrfical  perineal  veins ;  7,  dorsalis  clito- 
ridis vein ;  8,  9,  10,  pudic  vein  and  primary  liranclies ;  d,  tuberosity  of  iscliium ;  o, 
coccyx ;  6,  vulvo-vafiinal  jrland ;  «,  anterior  border  of  gluteus  raaxiinus  muscle ; 
b,  superficial  sphincter  and  muscle;  ff,  erector  clitoridis  muscle;  h,  left  crus  cli- 
toridis. 

rower  toward  its  orifice.  These  duets,  in  tlieir  course,  run  along  the 
inner  side  of  the  vaginal  bulbs,  and  terminate  in  front  of  the  hymen, 
about  midway  from  the  base  of  the  vestibule  and  the  posterior  border 
of  the  hymen,  or  its  remains. 


DISEASES  OF  THE   EXTERNAL   ORGANS  OF  GENERATION.      SI 

The  remaining  deeper  structures  of  the  pudendum  of  special  in- 
terest are  celkilar  tissue  and  two  masses  of  blood-vessels,  known  as 
the  bulbi  vestibuli  vaginoe.  These  bulbs  of  the  vaginal  vestibule 
are,  w^hen  distended  with  blood,  about  an  inch  long;  they  are  located 
on  each  side  between  the  vestibule  and  the  pubic  arch.  They  are 
composed  of  reticulated  veins  and  erectile  tissue.     The  upper  ends 


Fig.  45. — External  genitals  of  virgin. 

of  these  bulbs  are  pointed,  and  communicate,  by  an  intervening 
small  plexus,  the  pars  intermedia,  with  the  vessels  of  the  glans  cli- 
toridis  (Fig.  44). 

The  orificiura  vaginae  differs  greatly  in  size  and  general  appear- 
ance in  the  virgin,  in  those  accustomed  to  sexual  intercourse,  and  in 
those  who  have  borne  children  (see  Figs.  43  and  45). 
7 


82 


DISEASES  OF   WOMEN. 


In  virgins  the  hymen  is  present,  as  a  rule,  and  its  upper  crescen- 
tic  border,  with  its  concavity  looking  toward  the  urethral  opening, 
forms  the  vaginal  orifice.  There  is  a  considerable  variation  in  the 
shape  of  the  hymen,  and,  though  there  are  deviations  from  the  nor- 
mal type,  they  are  not  of  necessity  morbid  states,  but  rather  pecul- 
iarities of  formation.  The  most  common  of  these  are  the  hymen 
cribriformis  (Fig.  46),  which  has  a  number  of  small  openings  ;  the 


Fig.  46. — Cribriform  hymen.     Fig.  47. — Annular  hymen  {{).       Fig.  48. — Fimbriate  hymen. 

hymen  annularis  (Fig.  47),  which  has  one  small  central  opening; 
the  hymen  fimbriatus  (Fig.  48),  so  called  because  it  is  fringed  some 
what  like  the  extremity  of  a  Fallopian  tube. 

The  hymen  is  usually  lacerated  in  several  places  during  the  first 
coitus,  but  in  some  instances  this  does  not  take  place.  Cases  have 
been  seen  in  married  women  in  whom  the  hy- 
men is  very  elastic  and  distensible.  Hyrtl  men- 
tions one  specimen,  in  the  museum  at  Ilalle, 
where  the  hymen  is  perfect  though  the  woman 
had  given  birth  to  a  seven-months'  child.  The 
carunculfe  myrtiformes  are  a  number  of  iso- 
lated elevations  of  mucous  tissue  about  the  ori- 
fice of  the  vagina,  which  most  authors  claim 
to  be  the  remains  of  the  lacerated  hymen. 
Schroeder  has  pointed  out  that  these  elevations 
or  carunculiv  are  ])roduced  by  child-bearing, 
and  not  by  simple  laceration  of  the  hymen. 
Clinical  observations  confirm  the  views  of  Schroeder. 

Development  aud  Malformations  of  the  Vulva. — During  the  second 
month  of  fetal  life  tlie  rectuiii.  allaiiti>is,  and  Miiller's  ducts  com- 
municate, but  there  is  as  yet  no  opening  of  these  to  the  exterior 
(Fig.  49). 


Fig.  49. — B,  rectum,  con- 
tinuous with  All,  al- 
lantoi.s  (bladder)  and 
.»/ duct  of  Miiller( va- 
gina) ;  X,  depression 
of  skin  which  grows 
inward  and  forms  the 
vulva  (Schroeder). 


DISEASES  OF   THE  EXTERNAL  ORGANS  OP  GENERATION.      83 


Fig.  50. — The  depression 
has  extended  inward 
and  become  continuous 
with  the  rectum  and 
allantois,  forming  the 
cloaca  (CI). 


Fig.  51-. — The  cloaca  i8 
dividing:  into  urogen- 
ital sinus  (<S'm)  and 
anus  by  downward 
growth  of  perineal 
septum. 


Later  on,  al)out  the  teiitli  week,  the  genital  cleft  forms  ;  this  is  a 
depression  in  the  skin  which  gradually  extends  deeper  and  deeper 
until  it  comniunicates  with 
the  allantois  and  the  rectum, 
and    becomes     the     cloaca 
(Fig.  50). 

The  structure  which  lies 
between  the  rectum  and  the 
allantois  grows  in  a  down- 
ward direction,  dividing  the 
cloaca  into  two  parts  ;  that 
which  is  situated  anteriorly 
is  the  urogenital  sinus  into  which  Miiller's  ducts  open  ;  the  posterior 
part  becomes  the  anus,  while  the  lower  end  of  this  downward  growth 
forms  the  perinseum  (Fig.  51). 

The  upper  portion  of  the  urogenital  sinus,  becoming  more  and 
more  contracted,  forms  the  urethra,  the  lower  part  remaining  as  the 
vestibule  (Figs.  52  and  53). 

As  has  elsewhere  been  stated,  the  ducts  of  Miiller  unite  to  form 
the  vagina.     The  clitoris  is  formed  from  the  genital  eminence,  and 

the  labia  minora  from 
the  edges  of  the  geni- 
tal cleft. 

From  this  brief 
consideration  of  the 
manner  of  formation 
and  development  of 
the  external  genital 
organs  their  malfor- 
mations are  the  more  readily  understood.  Thus,  if  the  depression 
which  is  known  as  the  genital  cleft  fails  to  be  formed,  complete 
atresia  of  the  vulva  results.  If  the  partition  between  the  rectum  and 
vagina  is  not  developed,  the  condition  known  as  atresia  of  the  anus 
results.  From  the  description  already  given,  it  will  be  seen  that  this 
is  nothing  more  than  the  continuance  of  the  cloaca.  In  other  cases 
the  urethra  fails  to  be  developed,  and  there  is  then  a  persistence  of 
the  urogenital  sinus,  or  what  is  commonly  known  as  hypospadias. 

Hermaphroditism. — In  hermaphroditism  both  ovaries  and  testi- 
cles, or  one  of  each,  exist  in  the  same  individual  ;  these  cases  are 
extremely  rare,  though  they  have  been  observed  and  described  by 
Hildebrandt,  Bannon,  and  others.  In  false  or  pseudo-herniaphro- 
ditisni  a  condition  exists  in  which  the  external  genitals  appear  to 


Fig.  52. — The  perineal  body 
is  completely  formed 
(Schroeder). 


Fig.  53. — The  upper  part  of 
the  urogenital  sinus  has 
contracted  into theurethra; 
the  lower  portion  persists 
as  the  vestibule  {Su) 
(Schroeder). 


84 


DISEASES   OF  WOMEN. 


belong  to  the  opposite  sex.  Thus,  the  clitoris  may  be  so  hypertro- 
phied  as  to  resemble  a  penis,  and  the  labia  minora  be  so  closely  in 
apposition  as  to  be  mistaken  for  a  scrotum ;  or,  on  the  other  hand, 
the  individual  may  be  in  reality  a  male,  in  whom  the  condition  of 
hypospadias  may  exist,  and  thus  the  appearances  seem  to  indicate  a 
female.  A  case  is  reported  by  Otto,  in  which  the  external  genitals 
of  the  individual  so  resembled  those  of  a  female  that  he  lived  as  the 
wife  of  three  husbands  without 
the  fact  that  he  was  a  male  being 
discovered ;  and  then  the  mys- 
tery was  only  solved  by  medical 
examination.  Fig.  54  represents 
the  appearance  of  the  organs  in 
this  remarkable  case.  In  these 
cases  of  false  hermaphroditism 
careful  examination  will  settle 
any  doubts  which  may  have  aris- 
en. The  parts  simulating  both 
scrotum  and  labia,  when  exam- 
ined, will,  if  the  individual  is  a 
male,  contain  the  testicles  ;  and, 
if  a  female,  no  such  body  will  be 
found. 

It  is,  of  course,  to  be  borne 
in  mind,  that  owing  to  the  non- 
descent  of  the  testicle,  no  body 
might  be  found,  and  still  the 
individual  be  a  male,  and,  on  the 
other  hand,  that  a  prolapsed 
ovary  might  be  mistaken  for  a 
testicle.  A  digital  examination 
should  also  be  made  through  the 
rectum  for  the  uterus  and  ovaries 
rived,  the  presence  or  absence  of  menstruation  will  be  a  valuable 
diagnostic  sign,  and  great  aid  may  be  derived  from  a  study  of  the 
other  portions  of  the  body,  as  the  breasts  and  the  face,  in  order  to 
detect  the  beginning  beard,  or  the  voice,  to  distinguish  its  tones.  It 
is,  of  course,  very  important  to  make  a  correct  diagnosis ;  but  when 
this  is  done,  the  physician's  duty  is  at  an  end,  so  far  as  being  of 
any  service  to  the  patient. 


Fig. 


54. — Spurious  hermaphroditism  (Simp- 
son), case  of  hypospadias  in  tlie  male 
making  the  external  organs  simulate 
those  of  the  female  :  a,  a,  lobes  of  scro- 
tum ;  n,  imperforate  penis,  1^  inch  long; 
E,  perineal  fissure,  1|  inch  deep,  lined 
with  mucous  membrane,  at  bottom  of 
which  the  urethral  orifice,  d,  is  seen  ;  c, 
the  split  urethra  with  openings,  f,  of 
glands  beside  it. 

If  the  age  of  puberty  has  ar- 


DISEASES  OP  THE  EXTERNAL  ORGANS  OF  GENERATION.      85 

DISEASES    OF    THE    PUDENDUM. 

Vulvitis. — Primary  inflainmatiou  of  the  vulva  is  quite  rare,  if 
the  specitic  form  and  the  vulvitis  of  children  are  excluded.  In 
nearly  all  the  cases  that  have  come  under  my  observation  the  inflam- 
mation of  the  vulva  has  been  secondary  to  and  caused  by  some  pre- 
existing affection.  When  it  is  due  to  gonorrhoaa,  syphilis,  cancer  of 
the  uterus,  or  vaginitis,  it  must  necessarily  be  treated  as  a  complica- 
tion of  these  diseases,  rather  than  as  an  affection  in  and  of  itself. 

Uncomplicated  vulvitis  may  occur  in  several  forms — as  a  sim- 
ple erythema,  a  purulent  inflammation,  or  as  a  follicular  inflam- 
mation. 

The  erythematous  variety  is  characterized  by  a  general  redness  of 
the  vulva,  limited  to  the  mucous  surfaces,  though  sometimes  it  ex- 
tends to  the  skin.  It  is  usually  transient,  passing  away  without  much 
treatment. 

The  purulent  form  is  more  defined.  The  parts  are  red,  and  cov- 
ered with  a  copious  formation  of  pus.  The  epithelium  rapidly  ex- 
foliates, leaving  a  raw-looking  surface.  Occasionally  only  small 
patches  of  ulceration  are  to  be  seen,  but  these  are  neither  large  nor 
are  they  deep,  as  a  rule. 

In  follicular  vulvitis  the  mucous  membrane  generally  is  not  much 
chainged  in  appearance ;  sometimes  it  has  a  deeper  color,  but  the 
whole  surface  is  studded  wdth  small,  red  points,  which  on  close  in- 
vestigation are  found  to  be  the  orifices  of  mucous  follicles.  The 
size  and  number  of  these  inflamed  spots  vary  in  different  cases. 

In  this  and  in  the  purulent  form  the  discharge  is  increased  by  a 
free  secretion  from  the  mucous  and  sebaceous  glands,  and  this  gives 
rise  to  a  very  disagreeable  odor.  There  is  also  in  most  cases  consid- 
erable pruritus. 

Causation. — In  regard  to  the  causes  of  vulvitis,  it  is  evident  that 
the  strumous  diathesis  and  the  lymphatic  temperament  predispose  to 
it  All  the  cases  that  I  have  seen,  which  could  not  be  traced  to 
some  pre-existing  or  specific  cause,  have  been  in  strumous  or  phleg- 
matic women. 

Age  also  has  its  influence.  The  purulent  variety  occurs  in  chil- 
dren, while  the  follicular  form  occurs  most  frequently  in  the  aged. 

Symptomatology. — These  are  not  diagnostic.  The  discharge, 
heat,  tenderness,  and  pruritus  are  the  chief  symptoms,  but  they 
all  occur  when  the  vulvitis  is  associated  with  vaginitis,  and  similar 
symptoms  occur  in  many  of  the  eruptive  diseases  of  the  vulva. 

Physical  Signs. — These  are  the  same  as  those  presented  by  in- 


86  DISEASES  OF  WOMEN. 

flammation  of  mucous  membranes  generally,  and  hence  need  not  be 
given  here. 

Diagnosis. — This  is  made  by  inspection,  and  a  careful  exclusion 
of  all  other  affections,  such  as  eruptive,  specific,  or  malignant 
disease. 

I'reatment. — The  chief  objects,  in  the  management  of  vulvitis, 
are  to  keep  tlie  parts  clean,  and  to  separate  the  infiamed  surfaces. 
This  is  difficult  to  do  in  childi'en,  and  hence  the  complete  relief 
of  this  affection  in  the  young  is  not  by  any  means  easily  effected. 

In  vulvitis  of  women  I  have  of  late  years  relied  upon  frequent 
washing  with  a  solution  of  borax  or  boracic  acid,  two  or  three 
times  in  the  twenty-four  houi's,  and  then  after  drying  the  parts,  ap- 
plying thoroughly  a  dry  powder  of  subgullate  of  bismuth,  oxide  of 
zinc,  or  iodoform.  This  method  answers  very  well  if  the  patient 
has  a  nurse  who  can  carefully  employ  the  treatment.  Equally  good 
results  have  been  obtained  by  applying  to  the  parts,  after  bath- 
ing thoroughly,  a  solution  of  sulphate  of  zinc,  three  or  four  grains, 
three  ounces  of  water,  and  one  ounce  of  fluid  extract  of  hydrastis 
Canadensis,  or  nitrate  of  silver,  two  grains  to  the  ounce  of  water. 
After  applying  either  of  these  lotions,  a  small  pledget  of  absorb- 
ent cotton  should  be  placed  between  the  labia,  to  keep  the  surfaces 
apart,  and  to  absorb  the  purulent  discharge. 

Inflammation  of  the  Vulvo-vaginal  Glands.  —  Inflammation  of 
these  glands  in  the  great  majority  of  cases  is  due  to  vulvitis.  The 
inflammation  extends  into  the  ducts  and  finally  to  the  glands  them- 
selves. While  this  is  sometimes  the  result  in  simple  vulvitis,  it  is 
far  more  likely  to  occur  when  the  inflammation  is  gonorrha?al.  In 
some  cases  the  inflammation  does  not  extend  beyond  the  duct,  the 
gland  itself  escaping,  and  then  there  is  but  little  discomfort  experi- 
enced by  the  patient  unless  the  purulent  discharge  keeps  up  a  cir- 
cumscribed inflammation  of  the  vulva  around  the  opening  of  the 
ducts.  When  the  glands  are  involved,  the  symptoms  are  those  of 
an  inflammation  of  the  deeper  structures.  The  closing  of  the  ducts 
of  these  glands  may  result  in  the  formation  of  cysts,  by  the  retention 
of  the  secretion. 

S;/ni2>fom(it()logi/. — The  patient  will  usually  detect  the  inflamma- 
tory condition  l)efore  the  physician  is  consulted.  This  portion  of 
the  pudendum  will  be  hot,  sensitive,  and  painful ;  pruritus  may  also 
be  present. 

PJnjsical  Signs. — By  inspection  of  the  parts,  redness  around  the 
mouths  of  the  ducts  will  be  found.  The  openings  of  these  ducts 
are  to  be  sought  for,  about  the  middle  of  the  ostium  vagimij.  one  or 


DISEASES   OF   THE  EXTERNAL  ORGANS   OF   GENERATION.      87 

€ach  side,  just  in  front  of  the  hymen,  or  the  cariinculse  myrtiformes. 
By  palpation  a  hard,  circumscribed  tumor  will  be  found  at  the  loca- 
tion of  the  gland. 

Prognosis. — The  inflammation  may  gradually  subside,  or  result 
in  the  formation  of  an  abscess.  If  an  abscess  forms  it  will  pursue 
the  same  course,  and  be  recognized  in  the  same  manner  as  an  ab- 
scess elsewhere.  The  pus  may  discharge  through  the  duct,  or  it 
may  require  surgical  interference.  Rarely  the  pus  remains  encysted 
for  a  long  period.  The  inflammation  may  conflne  itself  to  the 
duct  and  not  extend  to  the  gland.  In  this  case  it  will  cause  but 
little  trouble,  pain  and  pruritus  being  present  for  a  short  time, 
and  disajipearing  with  the  subsidence  of  the  inflammation,  or  the 
inflammation  may  result  in  adhesion  of  the  wall  of  the  duct,  and,  by 
occluding  its  lumen,  prevent  the  escape  of  the  secretion  of  the  gland, 
and  cause  a  cyst  by  its  retention.  JSTot  infrequently  the  walls  of 
such  a  cyst  become  inflamed,  and  an  abscess  results. 

Treatment. — The  inflammation  of  these  glands  is  to  be  treated 
in  the  same  manner  as  is  recommended  for  the  treatment  of  in- 
flammation of  the  labia  majora. 

When  a  cyst  forms,  and  its  contents  can  not  be  evacuated  through 
the  duct  by  pressure,  it  may  be  dissected  out.  Although  the  great- 
est care  may  be  exercised,  this  can  not  always  be  done ;  in  that  case, 
the  cyst-wall,  after  being  exposed  by  dividing  the  mucous  mem- 
brane, may  be  opened  freely,  the  contents  of  the  sac  removed,  the 
wall  of  the  sac  thoroughly  cauterized  Avith  carbolic  acid,  and  the 
cavity  permitted  to  heal  from  the  bottom  by  granulation,  its  walls 
being  kept  separated  by  packing  with  cotton  in  order  to  prevent  its 
closino;',  and  ao-ain  flllino;. 

Inflammation  and  Abscess  of  the  Labia  Majora. — This  inflamma- 
tion occurs  in  the  connective  tissue,  which  constitutes  the  greater 
part  of  the  labia.  It  is  often  associated  with  vulvitis,  or  may  be 
due  to  the  secretions  of  the  vagina,  which  are  of  an  irritant  char- 
acter. Blows  or  other  injuries  may  also  excite  an  inflammation  in 
these  tissues.  This  inflammation  is  characterized  by  redness  and 
swelling;  the  latter  is  not  circumscribed,  as  in  the  inflammation  of 
the  vulvo-vaginal  glands,  but  is  more  diffuse.  Like  that,  however, 
it  is  painful,  and  accompanied  with  pruritus.  AYhen  a  swelling  is 
fonned  in  one  of  the  labia,  it  niay  be  due  to  simple  inflammation, 
or  it  may  be  a  hernia,  an  ovary,  or  a  hematocele. 

Treatment. — The  means  employed  for  the  treatment  of  inflam- 
mation of  connective  tissue  elsewhere  are  indicated  here.  These 
are  rest,  evaporating  lotions  containing  opium  for  the  relief  of  the 


88  DISEASES   OP  WOMEN. 

pain,  salines,  and  flaxseed-poiiltices  if  the  inflammation  does  not 
subside.  If  an  abscess  forms,  it  should  be  opened  as  soon  as  the 
presence  of  pus  is  determined  ;  the  opening  of  the  abscess,  and  the 
subsequent  treatment  of  the  wound,  should  be  managed  on  strictly 
antiseptic  principles. 

Varicose  Veins  of  the  Vulva. — The  veins  about  the  vulva,  like 
those  in  other  portions  of  the  body,  may  take  on  a  varicose  condi- 
tion. This  commonly  occurs  in  those  who  have  borne  children  ;  and, 
indeed,  pregnancy  appears  to  stand  in  a  causative  relation  thereto, 
although  cases  undoubtedly  do  occur  in  tliose  who  have  never  been, 
pregnant. 

Causation. — Anything  which  obstructs  the  venous  circulation 
-will,  by  increasing  the  intravenous  pressure,  tend  to  produce  this 
varicose  condition,  whether  it  be  a  pregnant  uterus,  a  tumor,  or,  as 
mentioned  by  Winckel,  the  straining  at  stool,  in  case  of  obstinate 
constipation, 

Symytomatology. — A  patient  may  have  well-marked  varicose 
veins  of  the  vulva,  and  yet  be  entirely  unaware  of  the  fact.  Or  a 
sense  of  heat  and  irritation  may  be  experienced  of  so  disagreeable 
a  nature  as  to  cause  her  to  consult  a  physician,  when  the  presence 
of  varicose  veins  may  be  recognized.  In  still  other  cases  the  full- 
ness due  to  the  swelling  is  so  great  as  to  attract  her  attention,  though 
other  symptoms  may  be  absent. 

Physical  Signs. — Upon  examination,  in  slight  cases,  the  varicose 
condition  of  the  veins  is  observed.  There  may,  however,  in  more 
aggravated  cases  be  so  much  tumefaction  of  the  labia  and  other  parts 
as  to  mask  this  peculiar  condition  of  the  veins.  Holden  describes  a 
case  in  which  a  tumor  existed  as  large  as  the  head  of  a  child. 

Tlie  diagnosis  in  these  cases  is  to  be  made  by  excluding  the  other 
affections,  by  the  methods  which  are  elsewhere  described. 

Treatment. — But  little  can  be  done  in  the  way  of  radical  treat- 
ment for  this  condition.  The  bowels  should  be  attended  to,  so  that 
tliere  may  not  be  constipation  and  the  accompanying  straining  at 
stool.  If  the  varicosity  is  marked,  and  shows  a  tendency  to  increase^ 
some  relief  may  be  obtained  by  a  pad,  so  applied  as  to  give  the 
veins  the  support  which  they  lack  by  reason  of  the  weakness  of 
their  walls.  It  should  be  constantly  borne  in  mind  that,  wlien  these 
veins  assume  a  marked  varicose  condition,  there  is  a  possibility  of 
their  becoming  so  distended  during  pregnancy  as  to  rupture  at  the 
time  of  deHvery. 

Wounds  of  the  Pudendum. — These  injuries  are  of  three  kinds — in- 
cised, punctured,  and  ccjiitused.     They  are  of  great  interest,  owing 


DISEASES   OF   THE   EXTERNAL   ORGANS   OF   GENERATION.      89 

to  the  profuse  haemorrhage  which  usually  occurs  when  the  vessels 
of  the  bulbi  vestibulares  are  wounded.  Superticial  wounds  of  the 
labia  are  not  usually  important ;  it  is  only  when  the  larger  vessels 
of  the  bulbi  are  opened  that  profuse  and  dangerous  haemorrhage 
occurs. 

Incised  and  punctured  wounds  are  usually  caused  by  falling  upon 
cutting  instruments.  I  have  not  had  any  personal  experience  with 
such  injuries.  All  I  know  about  them  I  have  gathered  from  Sir 
James  Y.  Simpson's  obstetric  work.  Pie  calls  attention  to  several 
fatal  cases  of  this  injury,  death  occurring  from  haemorrhage.  He 
also  states  that  several  of  these  fatal  cases  were  supposed  to  be  caused 
by  criminal  intent.  I  remember,  when  a  boy,  reading  an  account  of 
a  gypsy  woman,  in  Scotland,  who  died  from  pudendal  haemorrhage, 
and  her  husband  was  tried  for  her  murder.  The  defense  set  up 
was,  that  the  wound  was  caused  by  striking  against  a  stick  while 
squatting  down  to  urinate,  in  the  woods,  where  they  were  encamped. 

Thomas  records  a  case,  not  fatal,  I  believe,  which  was  caused  by 
a  piece  of  china,  from  the  breaking  of  a  ])ot  de  chamhre. 

Symptomatolocjy . — The  symptoms  are  pain  and  profuse  haemor- 
rhage, following  an  injury  to  these  parts.  The  bleeding  is  suffi- 
ciently alarming  to  require  an  examination,  when  the  character  of 
the  injury  is  at  once  detected. 

Causation. — The  causes  are  traumatic,  and  need  not  be  discussed. 

Treatment . — The  treatment,  commended  by  most  authors,  is  to 
use  cold  applications  and  astringents,  such  as  persulphate  of  iron  and 
tannin,  and  if  these  are  not  sufficient,  to  enlarge  the  wound,  pack 
it  with  antiseptic  cotton,  and  appl}^  pressure.  To  make  the  pressure 
effectual,  the  vagina  should  be  tamponed,  and  a  compress  and  band- 
age applied. 

I  am  satisfied  that  this  kind  of  treatment  must  prove  very  un- 
satisfactory. Although  I  have  had  but  little  experience  with  acci- 
dental injuries  of  the  pudendum,  I  have  repeatedly  encountered  pro- 
fuse bleeding  from  vessels  of  the  bulb,  wounded  while  removing 
morbid  gro\vths  from  the  pudendum.  In  such  cases  I  have  found 
it  most  satisfactory  to  ligate  the  bleeding  points,  taking  up  the  ves- 
sels en  masse  when  several  of  them  were  wounded ;  when  it  has 
been  difficult  to  find  the  vessels  and  secure  them  in  the  deep  wounds, 
1  have  passed  a  strong  suture  from  the  outer  side  of  the  labia  into 
the  vagina,  and  returned  it  so  that  it  would  include  the  bleeding 
vessels  in  its  grasp  when  tightly  tied.  This  controls  the  bleeding 
for  the  time,  but  occasionally  it  will  start  again,  when  the  ligature 
becomes  loosened,  which  it  is  likely  to  do  in  a  few  hours.     When 


90  DISEASES   OF    WOMEN. 

this  occurs,  the  ligature  should  be  tightened.  If  there  is  no  subse- 
quent bleeding,  the  suture  can  be  removed  at  the  end  of  twenty-four 
hours.  I  am  sure  that  this  is  the  most  surgical  as  well  as  the  most 
satisfactory  way  of  managing  haemorrhage  in  this  region.  Styptics 
and  pressure,  in  some  cases,  will  only  conceal  the  bleeding,  but  not 
arrest  it ;  the  blood  will  burrow  in  the  soft  tissues  and  complicate 
the  injury,  and  also  make  ligature  of  the  vessels  more  difficult. 

Contused  Wounds  of  the  Pudendum. — These  are  of  two  degrees  of 
severity.  A  slight  bruise,  causing  rupture  of  only  a  few  small  ves- 
sels (which  very  soon  stop  bleeding),  gives  rise  to  an  ecchymosis, 
which  quickly  disappears.  Occasionally  inflammation  follows  and 
an  abscess  develops,  which  is  managed  in  the  usual  way. 

Contused  wounds,  which  rupture  the  large  vessels  of  the  bulbi 
vestibulares,  or  varicose  veins  of  the  labia,  if  any  such  exist,  produce 
pudendal  h?ematocele — i.  e.,  an  accumulation  of  blood  in  the  loose 
cellular  tissue  of  the  parts.  The  pathology  of  this  injury  is  the 
same  as  that  of  bruises  or  contused  wounds  generally.  There  are 
lacei-ation  of  the  vessels,  and  haemorrhage  into  tlie  cellular  tissue. 

In  contusion  of  the  pudendum  there  are  two  conditions  which 
conspire  to  make  the  injury  grave  in  character — the  large  size  of 
the  vessels  wounded,  and  the  loose  character  of  the  cellular  tissue, 
which  admits  of  a  very  large  accumulation  of  blood.  The  size 
of  the  hfematocele  depends  upon  the  size  of  the  vessels  lacerated. 
In  case  the  vessel  is  small,  the  bleeding  may  be  controlled  by  the 
pi-essure  from  the  blood  in  the  tissues ;  but  when  large  varicose  ves- 
sels or  the  vessels  of  the  bulb  of  the  vestibule  are  lacerated,  the  size 
of  the  hsematocele  is  very  great.  I  have  seen  one  nearly  as  large  as 
the  two  fists. 

The  course  and  termination  of  luematocele  vary.  If  the  blood- 
clot  is  small,  it  may  disapi:)ear  by  absor])tion,  without  causing  much 
discomfort,  after  the  first  ])ain  of  the  injury  subsides ;  but  when  the 
accumulation  of  blood  is  large,  then  infiammation  follows,  which  may 
terminate  in  sloughing  or  suppuration,  and  filnally  septica?niia. 

SijmptohiatoJofjy. — The  symptoms  are  pain  following  the  injury, 
and  then  a  feeling  of  fullness,  heat,  and  sometimes  throbbing.  In 
one  case  that  came  under  my  observation  the  ]n'essure  was  sufficient 
to  prevent  unnatioii,  and  it  was  very  difficult  to  pass  the  catheter. 
The  attentio7i  of  the  patient  being  directed  to  tlie  location  of  the 
injury,  the  swelling  is  discovered  by  the  touch. 

Physical  Sigm-t. — The  ])hysical  signs  vary  in  the  different  stages 
of  the  disease.  At  first,  the  tumor  is  elastic  and  like  a  local  oedema, 
except  that  it  does  not  pit  on  pressure.     After  the  blood  has  coagu- 


DISEASES   OF   THE   EXTERNAL   ORGANS   OF   GENERATION.      91 

lated  the  parts  are  denser  and  slightly  irregular,  or  slightly  nodu- 
lar ;  discoloration  of  the  skin  occurs  in  twenty-four  hours,  or  less. 
(Edema  of  the  skin  also  appeais. 

Diagnosis. — In  regard  to  the  diagnosis,  it  may  be  said  that 
pudendal  hsematocele  can  hardly  be  confounded  with  any  of  the 
diseases  of  the  pudendum,  except  pudendal  hernia,  and  the  mode  of 
development  and  piiysical  signs  of  the  two  affections  are  so  unlike 
that  the  differentiation  is  easy. 

Causation. — The  causes  of  pudendal  haBmatocele  are  predispos- 
ing and  exciting.  Varicose  conditions  of  the  vessels,  degeneration 
of  the  vessel-walls,  and  marked  engorgement  from  any  cause  which 
interrupts  the  venous  circulation,  render  the  vessels  more  liable  to 
rupture  when  subjected  to  any  injury. 

Pregnancy  predisposes  to  rupture  of  the  pudendal  vessels,  and 
labor  is  one  of  the  most  prominent  of  the  exciting  causes,  but  the 
present  discussion  of  this  affection  is  limited  to  causes  occurring  in 
the  non-puerperal  state.  The  reader  will  find  a  very  full  account  of 
this  affection,  as  it  occurs  in  labor,  in  a  monograph  by  Prof.  Fordyce 
Barker. 

In  regard  to  the  exciting  causes  of  the  affection,  it  may  be  said, 
in  brief,  that  they  are  always  traumatic.  Direct  blows  are  the 
usual  means  by  which  the  vessels  are  ruptured ;  indirect  injuries — 
from  a  fall,  for  instance — might  produce  rupture  of  the  puciendal 
vessels,  but  I  have  not  seen  any  cases  in  which  the  injury  was 
caused  in  that  way. 

Treatment. — When  the  patient  is  seen  immediately,  and  while 
h?einorrhage  is  still  going  on,  an  effort  may  be  made  to  arrest  the 
bleeding  by  pressure ;  but  if  this  fails  after  a  short  trial,  it  is  best  to 
lay  the  parts  open,  and  secure  the  bleeding  vessels  in  the  way  already 
described.  This  is  quite  an  important  operation,  and  requires  that 
the  patient  should  be  anaesthetized,  but  the  results  fully  justify  the 
means.  The  advantages  of  this  treatment  are  threefold :  the  bleed- 
ing is  controlled  effectually,  and  in  the  safest  way,  providing  the 
surgeon  is  called  while  the  bleeding  is  still  going  on  ;  the  extent  of 
inflammatory  action  is  greatly  lessened  or  wholly  avoided ;  and  the 
dangers  of  septicaemia  are  guarded  against  by  clearing  out  the  blood- 
clots  and  securing  free  drainage.  The  rule  is,  however,  that  the 
surgeon  is  not  called  until  the  stage  of  bleeding  is  past ;  it  is  then 
well  to  wait  till  the  patient  has  recovered  from  the  loss  of  blood,  and 
reaction  from  the  shock,  if  there  has  been  any,  has  set  in,  and  then 
lay  open  the  hematocele,  turn  out  the  clots,  tie  any  vessels  that  may 
bleed,  secure  free  drainage,  and  use  ordinary  surgical  dressing,     I 


92  DISEASES  OF  WOMEN. 

am  sure  that  tliis  course  of  treatment  is  the  1)est,  being  by  far  the 
safest  in  guarding  against  fatal  septicjpmia,  and  securing  a  more 
prompt  convalescence,  with  iniinitelj  less  danger  to  the  tissues  of 
the  pudendum, 

ILLUSTRATIVE    CASE. 

Pudendal  Haematoma. — A  dissipated  woman,  about  forty  years  of 
age,  was  brought  into  the  Long  Island  College  Hospital,  after  having 
received  a  brutal  beating  from  her  husband.  She  had  a  number  of 
bruises  about  her  head  and  face,  and  complained  of  pain  in  the  puden- 
dum. On  examination,  an  enormous  swelling  was  found  in  the  region 
of  the  right  labium.  Pressure  was  made  by  means  of  bandages,  and 
the  swelling,  due,  no  doubt,  to  haemorrhage,  was  controlled  so  that 
it  did  not  increase.  She  had  considerable  fever  and  depression  from 
her  injuries,  but  was  rallied  by  means  of  stimulants  and  quinine. 
At  the  end  of  forty-eight  hours  after  her  admission  the  ecchymosis 
was  so  marked,  and  pressure  upon  the  tissues  so  great,  that  slough- 
ing was  apprehended  ;  even  if  that  should  not  take  place,  the  exten- 
sive inflammation  and  suppuration,  which  necessarily  must  follow, 
would  have  placed  the  patient's  life  in  great  danger  from  septicaemia, 
and  made  convalescence,  at  least,  very  tedious. 

It  was  tlierefore  decided  to  operate,  which  was  done  as  follows : 
An  incision  al)out  four  inches  long  was  made  on  the  inner  side  of 
the  tumor  with  the  thermo-cautery  knife.  Proceeding  slowly  with 
the  insti-ument  at  a  dull-red  heat,  no  hsemorrhage  was  excited  by 
the  incision.  The  clot,  a  very  large  one,  was  turned  out,  and,  just 
as  soon  as  the  pressure  was  removed,  bleeding  started  at  several 
points  in  the  deeper  portion  of  the  wound.  The  bleeding  vessels 
were  caught  up  by  compression-forceps  and  ligated,  and  the  general 
oozing  which  ke])t  up  was  controlled  by  the  cautery.  The  wound 
was  then  j^acked  with  lint,  which  was  held  in  place  by  a  bandage ; 
the  dressing  was  changed  night  and  morning,  the  quantity  of  lint 
being  reduced  as  the  cavity  contracted. 

She  made  an  excellent  recovery,  and  left  the  hospital  in  two 
weeks  from  the  time  of  the  operation. 

Hernia  of  the  Pudendum. — Two  varieties  of  hernia  ma}'  occur  in 
the  vulva — one  known  as  anterior-labial,  and  the  other  as  poste- 
rior-labial. The  former,  which  is  sometimes  described  as  inguinal 
labial  hernia,  consists  in  the  passage  of  the  dislocated  organ  by  the 
side  of  the  round  ligament  into  a  labium  majus.  The  sac  may  con- 
tain intestine,  omentum,  ovary.  Fallopian  tube,  or  uterus.  AVinckel 
found  six  cases  of  this  variety  of  hernia  in  .5,000  private  patients  ex- 
amined by  him ;  in  one  case  an  ovary  was  found  in  the  left  side ; 


DISEASES   OF   TILE   EXTERNAL   ORGANS   OF   GENERATION.      93 

in  a  second,  eacli  ovary  in  a  hernial  sac  ;  in  a  third,  the  utenis ;  and 
in  a  fourth,  the  pregnant  uterus. 

The  second  variety,  known  also  as  vagino-labial  hernia,  occurs 
much  less  frequently,  Winckel  has  seen  but  two  cases,  and  says  that 
the  hernia  passes  down  in  front  of  the  broad  ligament  into  an  open- 
ing in  the  pelvic  fascia  and  levator  ani,  and  appears  at  the  posterior 
extremity  of  one  of  the  labia  majora. 

Diagnosis. — This  is  not  difficult,  if  due  caution  and  care  be  ex- 
ercised. If  the  patient  bears  down,  the  size  of  the  tumor  will  be 
increased.  If  she  be  placed  in  the  knee-chest  position,  the  hernia 
can  be  readily  reduced,  going  back  with  a  gurghng  sound.  When 
she  assumes  an  upright  position,  the  reduced  tumor  will  again 
return. 

Treatment — This  consists  in  reducing  the  hernia,  and  retaining 
the  organ  in  place  by  means  of  a  properly -applied  truss. 

Vaginal  Enterocele. — This  is  a  form  of  hernia  in  which  the  intes- 
tines descend  into  the  pelvic  cavity,  and  may  pass  down  either  in 
front  of  or  behind  one  of  the  broad  ligaments. 

The  hernia  is  usually  composed  of  small  intestine  alone,  though 
it  may  contain  omentum  alone,  or  both  intestine  and  omentum  to- 
gether. Cases  have  been  recorded  in  which  the  large  intestine  came 
down  instead  of  the  small  one. 

Vaginal  enterocele  is  usually  explained  in  the  following  manner : 
The  intestine,  having  found  its  way  into  Douglas's  ciil-de-saG,  pushes 
it  downward,  and  gradually  causes  the  vagina  to  bulge  inward.  This 
may  increase  to  such  a  degree  that,  finally,  the  tumor  may  appear  at 
the  vulva  and  even  protrude  from  it. 

Diagnosis. — This  is  not  difficult  if  the  examination  is  made  with 
care,  though  serious  errors  have  been  made  by  surgeons,  the  tumor 
being  considered  an  abscess,  and  opened  by  the  knife. 

A  vaginal  enterocele  may  be  recognized  by  the  following  char- 
acteristics :  It  becomes  smaller  on  pressure ;  increases  in  size  when 
the  patient  coughs  or  bears  down  ;  is  resonant  on  percussion — though, 
if  the  contents  are  omentum,  this  sign  would  not  be  present — and  is 
easily  returned  if  the  patient  be  placed  in  the  knee-chest  position. 
It  may  be  mistaken  for  an  abscess,  a  prolapsus  of  the  vagina,  an 
ovarian  cyst,  or  a  dropsy  of  the  Fallopian  tubes. 

Causation. — Parturition  is  considered  as  the  most  common  cause 
of  the  hernia,  the  intestines  being  pressed  down  against  the  relaxed 
pelvic  tissues  by  the  expulsive  pain  of  labor.  When  occurrhig  in 
nulliparous  patients,  it  is  usually  due  to  falls  or  to  violent  straining 
efforts. 


9J:  DISEASES   OF   WOMEN. 

Treatment. — Inasmuch  as  the  sac  of  this  variety  of  hernia  is  not 
liable  to  constriction,  strangulation  rarely  occurs.  The  tumor  will 
disappear  if  the  patient  is  placed  in  the  knee-chest  position,  and  its 
retention  may  usually  be  accomplished  by  a  pessary  that  will  keep 
the  vaginal  wall  tense.  This  will  at  least  prevent  the  protrusion  of 
the  hernia  from  the  vulva,  though  it  is  doubtful  if  any  treatment 
will  prevent  entirely  the  entrance  of  the  intestines  into  the  pelvic 
cavity.  The  existence  of  this  hernia  should  be  borne  in  mind  in 
case  the  patient  becomes  pregnant,  for  under  such  circumstances 
labor  is  often  impeded  by  the  enterocele,  which,  coming  down  in 
advance  of  the  presenting  part,  olf  ers  a  serious  obstacle  to  its  progress. 

Hydrocele  of  the  Round  Ligament. — In  order  to  understand  the 
condition  which  is  present  in  hydrocele,  it  is  necessary  to  recall  the 
anatomical  relations  of  the  round  ligaments  and  the  labia  majora. 

The  labia,  it  will  be  remembered,  are  the  analogues  of  the  male 
scrotum,  and  the  round  ligament  of  the  spermatic  cord.  These  liga- 
ments terminate  in  the  labia  majora,  and  are  covered  by  an  offshoot 
from  the  peritonaeum,  the  increased  serous  secretion  formed  by  this 
membrane  constituting  hydrocele. 

Althougli  the  peritoneal  sac  does  not  ordinarily  extend  into  the 
inguinal  canal,  still  it  may  do  so,  and  intestine  or  an  ovary  may  en- 
ter tliis  pouch.  Hydrocele  of  the  round  ligament  is  liable  to  be 
confounded  with  hernia.  The  tumor  will  be  translucent  if  it  be 
hvdrocele,  and  this,  together  with  the  history,  will  be  sufficient  to 
make  the  diagnosis.  An  aspirator  needle  may  be  employed  to  make 
the  diagnosis  more  certain.  It  is  an  exceedingly  rare  disease,  and 
one  that  I  liave  never  seen. 

Treatment. — The  fluid  contents  of  the  sac  should  be  withdrawn 
by  aspiration,  and  tincture  of  iodine  injected. 

Hyperaesthesia  of  the  Vulva. — This  disease,  as  the  name  implies^ 
is  characterized  l)y  a  supersensitiveness  of  the  vulva.  Pruritus  is 
absent,  and  on  examination  of  the  parts  affected  no  redness  or  other 
extenial  manifestation  of  the  disease  is  visible.  When,  however^ 
the  examining  finger  comes  in  contact  with  the  hyi^erassthetic  part, 
the  patient  complains  of  pain,  which  is  sometimes  so  great  as  to 
cause  her  to  cry  out.  Indeed,  the  sensitiveness  is  occasionally  so 
exaggerated  as  to  keep  the  patient  from  consulting  her  physician 
until  it  becomes  absolutely  intolerable.  Sexual  intercourse  is  equally 
painful,  and  becomes  in  aggravated  cases  impossible. 

This  affection  must  not  be  confounded  with  vaginismus,  or  with 
other  conditions  of  increased  sensitiveness  of  the  vulva  due  to  in- 
flammatorv  conditions. 


DISEASES   OF   THE   EXTERXAIj   ORGANS   OF   GENERATION.      0.> 

Caumtloii. — The  causes  which  produce  this  hypersesthetic  con- 
dition of  the  vulva,  when  not  due  to  inflammation  or  the  presence 
of  urethral  tmnors,  are  difficult  to  recognize.  At  the  menopause 
the  affection  seems  more  likely  to  oecm-  than  at  any  other  period  of 
life,  and  women  of  weak  mental  and  physical  powers  are  more  often 
its  siiljjects  than  those  who  are  strong  both  in  mind  and  hody. 

Treatment. — Various  methods  of  treatment  have  been  suggested, 
but  so  far  as  my  own  experience  is  concerned  they  have  been  iu 
most  instances  unsatisfactory.  The  sensitive  tissue  has  been  dis- 
sected off  and  relief  obtained  for  a  time,  the  hyperaesthesia  return- 
ing, however,  as  before  the  operation.  Nitric  acid  has  been  ap- 
plied, but  without  a  cure  resulting.  The  best  that  we  can  probably 
do  for  our  patients  is  to  bnild  them  up  with  tonics  and  nutritious 
food,  and,  if  possible,  to  send  them  away  so  that  they  can  have  tlie 
benefit  of  a  change  of  air  and  of  scene,  and  at  the  same  time  be  re- 
moved from  the  irritation  of  sexual  intercourse,  which  of  necessity 
aggravates  and  perpetuates  the  hypersesthesia.  I  have  repeatedly- 
been  able  to  relieve  the  hyperagsthesia,  temporarily,  by  the  applica- 
tion of  cocaine  in  a  four-per-ceut  solution.  This  will  also  be  found 
useful  when  making  examinations  in  cases  of  sensitive  vulva,  or  in 
passing  the  sound  into  a  sensitive  uterus. 

Pruritus  Vulvae. — This  condition  is  a  symptom  rather  than  a  dis- 
ease in  and  of  itself,  and  yet  it  is  such  a  prominent  one  in  many  cases, 
as  to  justify  its  description  as  an  independent  affection. 

Pathology. — Pruritus  consists  essentially  in  an  irritable  condition 
of  the  nerves  of  the  part  affected.  Although  this  is  ordinarily  the 
vulva,  it  may  be  and  often  is  the  vagina  and  the  anus,  and  even  the 
integument  of  the  abdomen  and  thighs  may  be  involved. 

SymjytomaAology . — The  patient  notices  an  itching  of  the  parts- 
affected,  which  is  at  first  relieved  by  scratching  or  rubbing,  but  later 
this  relief  is  but  temporary,  and  the  friction  aggravates  the  original 
trouble,  until  an  eruption  of  an  irritating  nature  appears,  from  which 
at  a  still  later  period  there  is  an  exudation,  which,  by  the  nails  used 
in  scratching,  or  in  other  ways,  is  carried  to  other  portions  of  the 
body,  and  seems  by  its  irritant  nature  to  excite  a  similar  trouble 
there.  The  itching  and  the  burning  sensations  become  at  times  in- 
tolerable, and  the  patient  is  debarred  from  the  society  of  her  friends. 
In  some  instances  the  annoyance  and  suffering  are  increased  at  night, 
and  in  order  to  obtain  sleep  hypnotics  have  to  be  administered. 

Physical  Signs. — The  signs  vary  according  to  the  affections 
which  cause  the  irritation.  These  are  described  above  in  speaking 
of  the  pathology.     In  some  cases  there  are  no  definite  signs  present. 


96  DISEASES   OF  WOMEN. 

Causation. — It  is  more  than  probable  that  pruritus  is  always 
secondary  to  some  other  trouble.  A  due  appreciation  of  this  fact  is 
necessary  for  the  institution  of  ])roper  treatment,  as,  if  it  is  lost  sight 
of,  and  that  which  is  in  reality  only  a  symptom  is  regarded  as  a  disease, 
the  pruritus  will  continue  ahnost  indefinitely,  and  in  its  chronic  form 
will  resist  all  remedial  measures.  Leucorrhoea  is  very  commonly  as- 
sociated with  pruritus,  and  appears  to  stand  in  a  causative  relation 
thereto.  Other  irritating  fluids  may  also  produce  the  same  result. 
Of  these  the  most  common  are  diabetic  urine  and  the  discharges 
from  an  ulcerating  cancer  of  the  uterus.  The  leucorrhoeal  discharge 
which  is  most  likely  to  produce  pruritus  is  that  from  a  uterus  which 
is  the  seat  of  endometritis,  either  cervical  or  corporeal. 

The  presence  of  parasites  may  also  account  for  the  existence  of 
pruritus. 

Treatment. — From  the  principle  already  laid  down  that  pruritus 
is  to  be  regarded  as  a  symptom  of  some  pre-existing  disease,  the  de- 
tection of  this  disease  will  first  demand  attention,  and  when  discov- 
ered treatment  appropriate  thereto  should  follow.  If  there  be  an 
endometritis,  the  discharge  from  which  irritates  the  vulva  or  other 
parts,  and  causes  pruritus,  the  inflammation  should  be  treated  as 
advised  elsewhere. 

A  pledget  of  absorbent  cotton  placed  against  the  os,  to  receive 
the  discharge,  will  be  of  great  benefit ;  this  should,  of  course,  be 
renewed  sufficiently  often.  Yaginal  douches  containing  acetate  of 
lead  or  carbolic  acid  will  often  give  great  relief.  Subnitrate  of  bis- 
muth may  be  dusted  on  to  prevent  friction  of  the  labia  against  each 
other ;  this  sometimes  I'elieves  the  pruritus.  I  have  found  this  to 
be  one  of  the  best  local  applications  in  the  pruritus  caused  by  diabe- 
tes ;  in  such  cases  I  direct  the  patient  to  keep  the  urine  from  coming 
in  contact  with  the  parts,  as  far  as  possible,  when  urinating,  and  to 
dry  the  pudendum  and  dust  it  over  with  subnitrate  of  bismuth.  By 
adding  an  equal  quantity  of  prepared  chalk  to  the  bismuth,  it  makes 
a  powder  that  is  more  easily  used. 

Very  satisfactory  results  can  be  obtained  in  the  management  of 
cases  where  the  pruritus  is  caused  by  some  appreciable  disease  of  the 
organs.  The  greatest  difficulties  are  experienced,  however,  in  the 
treatment  of  that  form  of  pruritus  which  occurs  without  any  lesion 
of  structure  or  accompanying  affections  to  account  for  it.  That 
there  are  some  morbid  changes  in  the  tissues,  in  the  violent  pruritus 
which  is  experienced,  is  no  doubt  true,  but  so  far  they  have  not  been 
demonstrated  by  pathologists,  and  hence  the  majority  of  authors  con- 
sider that  this  affection  is  a  neurosis. 


DISEASES   OF   THE  EXTERNAL   ORGANS   OF   GENERATION.      97 

111  the  majority  of  cases  of  this  kind  that  have  come  under  riij 
observation,  the  skin  has  been  bleached,  in  spots  appearing  whiter 
than  the  normal  skin.  It  has  also  lost  the  normal  elasticity.  Tu  the 
touch  it  seems  harder  and  less  liexible,  but  what  these  changes  are, 
and  whether  they  are  related  to  the  pruritus,  are  questions  which 
have  not  yet  been  answered. 

The  pathology  and  causation  of  this  affection  are  both  obscure, 
and  the  treatment  is  equally  unsatisfactory.  Many  of  these  cases 
prove  to  be  incurable,  and  in  some  it  is  not  possible  to  give  the  patient 
complete  relief  by  any  local  treatment.  This  has  led  to  the  use  of  a 
great  variety  of  agents,  but  none  of  them  has  proved  to  be  reliable 
in  all  cases.  The  remedies  that  have  given  the  best  results  in  ray 
practice  are  bichloride  of  mercury  and  emulsion  of  bitter  almonds, 
one  grain  to  the  ounce ;  this  is  applied  to  the  parts  affected  twice  a 
day.  A  powder  composed  of  one  grain  of  morphine  to  two  grains 
of  chalk,  to  be  applied  night  and  morning ;  equal  parts  of  tincture 
of  opium,  iodine,  and  aconite,  and  eight  per  cent  of  carbolic  acid, 
applied  once  a  day — all  of  these  have  been  tried,  and  each  one  has 
proved  serviceable  to  some  extent,  but  there  are  cases  which  resist 
all  these  remedies. 

The  bichloride  of  mercury  mixture,  used  alone,  has  been  of  the 
most  service  in  the  largest  number  of  cases.  Where  it  fails,  I  have 
used  a  solution  of  iodoform  in  ether ;  this  is  applied  by  means  of  an 
atomizer,  and  by  using  strong  air-pressure  the  solution  is  forced  into 
all  the  folds  of  the  mucous  membrane ;  the  ether  soon  evaporates,  and 
leaves  a  fine  coating  of  the  iodoform  over  the  whole  surface.  This 
nearly  always  relieves,  and  if  applied  frequently  is  curative  in  some 
cases.  I  have  also  used  carbolic  acid  and  tincture  of  iodine,  equal 
parts,  and  this  nearly  always  gives  relief  for  a  day  or  more.  In  the 
following  case  this  application  relieved  the  pruritus  permanently : 

The  patient  had  passed  the  menojDause,  and,  although  she  had 
not  borne  children,  her  health  had  always  been  good.  Dr.  Fordyce 
Barker,  whom  she  consulted,  sent  her  to  me,  telling  her  at  the  same 
time  that  I  could  not  cure  her,  but  would  give  her  as  much  relief  as 
possible.  I  tried  the  usual  remedies,  with  no  benelit.  I  then  used 
the  carbolic  acid  and  iodine,  but  found  it  difficult  to  apply  to  all  the 
irregularities  of  the  surface.  I  applied  it  with  the  atomizer,  using 
a  high  pressure,  so  that  the  solution  was  forced  into  the  tissues,  and 
a  deeper  effect  obtained  than  I  had  expected.  The  result  of  this 
was,  that  the  patient  suffered  greatly.  The  first  effect  was  sharp 
pain,  followed  very  soon  by  relief  from  the  itching,  and  numbness 
of  the  parts;  in  short,  the  anaesthetic  effect  of  the  carbolic  acid  was 
8 


98  DISEASES  OF  WOMEN. 

obtained  in  a  marked  degree.  Following  this  there  were  great  irri- 
tation and  pain  ;  the  epithelial  layers  of  the  skin  and  mucous  mem- 
brane came  oil"  as  if  they  had  been  blistered,  and  there  was  much 
sensitiveness.  During  this,  while  the  patient  was  suffering  the 
most  pain,  she  said  that  it  caused  far  less  suffering  than  the  itching. 
When  she  recovered  from  the  treatment  the  itching  did  not  return 
for  several  weeks,  and  then  only  in  a  slight  degree.  I  made  the 
same  application  once  again  to  several  spots  where  there  was  severe 
itching,  being  careful  not  to  cover  more  than  a  very  small  area.  It 
was  not  necessary  to  apply  the  remedy  the  third  time. 

She  completely  recovered,  and  remained  well  for  one  year  at 
least ;  and  I  presume  she  has  had  no  2-e lapse,  as  I  should  probably 
have  heard  from  her  if  she  had. 

Eruptions  of  the  Vulva. — The  vulva  may  be  the  seat  of  eczema, 
either  acute  or  ciironic,  herpes,  prurigo,  erysipelas,  and  diphtheria. 

Eczema  here  as  elsewhere  consists  of  vesicles,  or  a  somewhat 
reddened  skin,  from  which  a  serous  fluid  escapes.  This  dries,  and 
oftentimes  a  thick  crust  forms,  under  which  pus  may  accumulate. 
If  the  attack  does  not  become  chronic,  this  crust  falls  off  in  one  or 
two  weeks,  exposing  a  new  and  tender  epidermis  beneath.  If,  on 
the  other  hand,  the  affection  becomes  chronic,  the  tissues  become 
thickened  by  exudation,  and  at  the  same  time  dry,  and  lose  their 
suppleness.  This  condition  is  very  liable  to  extend  to  the  thighs 
and  to  the  integument  about  the  mons  veneris  and  anus. 

In  herpes,  vesicles  are  also  present,  but  they  are  not  accompanied 
by  any  redness  or  inflammation  of  the  surrounding  tissues.  These 
vesicles  may  rupture  and  scales  result,  but,  like  herpetic  eruptions 
on  the  lips,  they  are  of  short  duration,  and  soon  disappear. 

In  prurigo,  small  papules  are  seen  on  the  affected  parts.  Kiilm 
describes  them  as  having  a  small,  dark  spot  in  the  center,  which  is 
depressed,  and  containing  a  tenacious,  reddish,  gland-like  mass  at- 
tached to  the  bottom  of  the  papilla. 

Treatment. — In  the  acute  form  of  eczema,  in  which  there  is  free 
transudation  of  serum,  I  use  subnitrate  of  bismuth  or  powdered  soap- 
stone,  with  three  to  Ave  per  cent  of  carbolic  acid.  When  the  parts 
are  dry,  I  employ  oxide-of-zinc  ointment,  carbolic-acid  ointment,  or 
glycerine  and  borax.  In  chronic  forms  of  eczema,  applications  of 
nitrate  of  silver,  twenty  grains  to  the  ounce  of  water,  may  be  made. 
This  may  be  done  once  or  twice  a  week.  The  herpetic  eruption 
will  disappear  without  treatment,  and  the  only  indication  is  to  keep 
the  affected  parts  protected  from  friction. 

Prurigo  may  be  cured,  according  to  Xiihn,  by  removing  these 


DISEASES   OF   THE  EXTERNAL   ORGANS  OP  GENERATION.      99 

tenacious  masses  which  have  been  described  as  situated  at  the  bottom 
of  the  papillffi. 

The  vulva  is  sometimes  the  seat  of  erjsipeLatous  and  diphtheritic 
inflammation.  Erysipelas  is  rare  in  adult  life,  and  indeed  may  be 
said  to  occur  most  frequently  in  the  very  earliest  infancy.  In  its 
local  treatment  sugar-of-lead  lotions  may  be  applied,  and  internally 
tonics  and  stimulants.  The  prescription  which  has  given  me  the 
most  satisfaction  is  as  follows :  Borax,  one  drachm ;  tincture  of 
opium,  one  ounce;  glycerin,  three  drachms;  and  water,  three 
ounces.     The  parts  should  be  kept  constantly  moistened  with  this. 

Diphtheria  of  the  vulva  occurs  in  some  cases  when  the  exudation 
exists  in  the  pharynx  or  larynx,  and  rarely  as  an  independent  disease. 
Its  treatment  is  constitutional. 

Noma,  or  gangrene  of  the  vulva,  is  perhaps  best  considered  in 
connection  with  the  eruptive  diseases.  The  first  indication  is  a 
swelling  of  one  of  the  labia  majora,  which  becomes  of  a  grayisb- 
green  color,  followed  by  vesicles ;  the  color  changes  to  brown,  and 
gangrene  rapidly  sets  in. 

Causation. — Noma  occurs  in  children  whose  general  health  is 
poor,  either  from  insufficient  and  improper  food,  or  from  having  lived 
in  squalid  tenement-houses ;  or,  indeed,  from  both  combined.  It 
may  also  occur  as  a  complication  of  one  of  tbe  contagious  diseases — 
scarlet  fever,  measles,  or  small-pox. 

The  prognosis  in  noma  is  very  grave. 

Treatment. — This  should  be  directed  to  sustaining  the  failing 
powers  of  the  patient.  For  this  purpose  quinine,  iron,  and  stimu- 
lants should  be  freely  administered,  and  antiseptic  dressings  applied 
to  the  affected  parts.  It  has  been  recommended  to  excise  the  gan- 
grenous tissue,  and  to  apply  the  actual  cautery  to  the  underlying 
parts. 


CHAPTER  YI. 


DISEASES    OF    THE    VAGINA. 


Anatomy  of  the  Vagina. — The  vagina  is  the  continuation  of  the 
genital  tract  from  the  uterus  to  the  vulva.  It  is  curved  to  coincide 
■with  the  axis  of  the  pelvic  excavation ;  this,  to  some  extent,  i-enders 
it  much  shorter  in  front  than  behind.  The  anterior  wall  is  about 
two  inches  long,  while  the  posterior  is  nearly  twice  that  length.  The 
anterior  wall  is  further  shortened 
by  the  cervix  uteri,  which  joins 
the  vagina  much  nearer  to  the  vul- 
va in  front. 

Fig.  55  shows  the  comparative 
length  of  the  vagina  in  front  and 
behind. 

The  vagina  is  attached  above 
to  the  cervix,  about  midway  be- 
tween the  body  of  the  uterus  and 
the  termination  of  the  cervix  uteri. 
Below,  it  unites  with  the  floor  of 
the  pelvis  and  the  structures  Avhich 
form  tlie  vulva.  Anteriorly,  it  is 
united  to  the  bladder  and  urethra ; 

to  the  former  loosely,  and  to  the  latter  so  firmly 
that  it  is  almost  impossible  to  separate  these 
structures  even  by  dissection.  Posteriorly,  the 
vagina  and  rectum  are  united  and  form  the 
recto-vaginal  septum.  Below,  they  are  se])a- 
rated  by  the  sphincter-ani  and  tranversus-perinei 
muscles  and  cellular  tissue.  Fig.  56  shows  the 
triangle  formed  by  the  bifurcation  of  the  two 
canals  and  the  divided  muscles  between  them. 
The  vesi CO- vaginal  septum  is  the  most  resist- 
100 


Fig.  55, — Length  of  vagina,  less  in  front 
than  behind. 


Fig.  56. — Triangiilar  shape 
of  perineal  body. 


DISEASES  OF   THE  VAGINA.  101 

ant  portion  of  the  vaginal  walls,  and,  when  put  upon  the  stretch, 
feels  like  a  cord  lying  beneath  the  mucous  layer ;  this  is  called  the 
anterior  column  of  the  vagina. 

The  vaginal  walls  are  composed  of  three  coats — an  external,  mid- 
dle, and  internal ;  the  external  consists  of  fibrous,  elastic,  and  areo- 
lar tissue ;  the  middle  of  unstriped  muscular  fiber ;  and  the  inter- 
nal of  mucous  membrane.  The  muscular  coat  is  continuous  with  the 
middle  coat  of  the  uterus,  and  the  two  are  alike  in  structure,  and  in 
the  fact  that  they  both  undergo  extraordinary  hypertrophy  during 
utero-gestation.  The  mucous  membrane  of  the  vagina  is  continuous 
with  the  endometrium,  but  differs  from  the  latter  in  structure  to  a 
marked  extent.  It  is  arranged  in  transverse  folds,  which  are  most 
prominent  anteriorly,  and  is  studded  with  papillae  and  covered  with 
pavement  epithelium.  In  general  structure  the  mucous  membrane 
of  the  vagina  resembles  very  much  the  skin.  This  is  noticeable  in 
cases  of  prolapsus,  in  which  the  membrane,  by  being  exposed,  be- 
comes dry  and  its  epithelium  hardened. 

The  stnicture  of  this  membrane  is  like  the  skin  to  some  extent — 
its  secretion  is  serous  and  of  acid  reaction.  There  has  been  some 
discussion  among  anatomists  regarding  the  presence  or  absence  of 
muciparous  glands  in  this  vaginal  membrane.  The  fact  is  that  they 
are  abundant  in  the  lower  third,  but  nearly  absent  in  the  middle  and 
upper  thirds. 

The  vagina  is  developed  like  the  uterus,  from  Muller's  ducts,  and 
is  hable  to  malformations  from  arrest  or  defects  of  development. 

Malformations  of  the  Vagina. — Imperforate  hymen  has  been  al- 
ready discussed  under  the  head  of  menstrual  disorders  due  to  mal- 
formations of  the  sexual  organs  generally. 

Double  vagina  usually  occurs  in  connection  with  double  uterus, 
and  in  such  cases  no  harm  to  the  patient  is  likely  to  result. 

Perpetuation  of  the  septum  between  the  most  dependent  por- 
tions of  Miiller's  ducts  has  been  found.  In  one  patient  who  came 
under  my  observation  a  thick  septum  extended  from  just  within  the 
hymen  upward  about  an  inch  and  three  quarters.  This  malforma- 
tion gave  rise  to  no  symptoms,  and  was  not  recognized  until  the 
birth  of  her  first  child,  when  the  attending  physician  found  that  it 
caused  some  obstruction  to  delivery.  I  examined  the  case  about  two 
months  after  her  confinement  and  found  this  septum,  about  a  quarter 
of  an  inch  thick  and  quite  resistant.  It  was  divided  by  two  incis- 
ions parallel  to  the  axis  of  the  vagina,  and  about  three  quarters  of 
an  inch  apart.  The  strip  thus  removed  was  not  the  whole  of  the 
septum,  but  it  was  sufficient,  as  the  ends  remained  contracted.     The 


102  DISEASES  OF  WOMEN. 

divided  edges  were  brought  together  Mith  sutures,  and  healing  took 
place  very  promjitly. 

Imperforate  Vagina. — Absence  of  the  vagina  has  been  described 
as  one  of  the  malformations,  but  it  is  doubtful  if  there  is  not  in 
these  cases  a  rudiment  of  vagina,  M-hich  is  imperforate,  and  hence 
absent  to  all  intents  and  purposes.  In  the  most  complete  case  of  the 
kind  that  I  have  seen  the  rectum  and  bladder  were  near  together. 
With  the  linger  in  the  rectmn.  and  a  large  sound  in  the  bladder,  a 
rather  dense  cord  running  upward  from  the  vulva  could  be  felt. 
The  uterus  was  also  rudimentary,  and  although  the  patient  had 
passed  the  period  of  puberty,  and  had  the  outward  characteristics 
of  her  sex,  she  had  never  menstruated.  This  was  evident  from  the 
absence  of  menstrual  flow  in  the  uterus  and  Fallopian  tubes. 

In  cases  like  this  nothing  can  be  gained  by  treatment.  So  long 
as  there  is  no  excessive  menstrual  molimen,  which  would  endanger 
the  life  of  the  patient,  there  should  be  no  interference. 

Atresia  of  the  Vagina. — This  is  the  more  common  affection.  It 
may  be  either  complete  or  partial,  congenital  or  acquired. 

In  the  congenital  form  the  atresia  may  extend  the  whole  length 
of  the  vagina,  and  that  condition  is  generally  associated  with  an  un- 
developed uterus.  The  incomplete,  or  partial,  atresia  is  usually  at 
the  lower  third,  but  it  may  occm'  at  the  upper  or  middle  portion  of 
the  vagina. 

Congenital  atresia  occurs  under  two  different  conditions.  The 
one  is  associated  with  defective  development  of  the  uterus  or 
ovaries,  or  both,  sufficient  to  prevent  menstruation  altogether.  In 
the  other,  menstruation  takes  place,  but  the  flow  being  obstructed, 
accumulation  occurs  in  the  uterus  and  sometimes  in  the  Fallopian 
tubes.  These  differing  conditions  require  different  management.  I 
will  therefore  consider  them  separately. 

Atresia  of  the  vagina,  with  defective  develojiment  of  the  uterus 
and  ovaries,  is  only  of  interest  with  reference  to  the  diagnosis.  Noth- 
ing can  be  done,  nor  is  there  any  active  demand  for  treatment.  The 
patient  does  not  suffer,  as  a  rule,  except  from  the  consciousness  of 
her  deformity,  which  would  only  cause  mental  distress  in  case  she 
intended  to  get  married. 

Two  such  cases  have  come  under  my  observation.  The  most 
typical  one  was  of  a  good  family,  strong,  but  inclined  to  flesh.  She 
did  not  cliange  much  in  general  appearance  at  puberty,  but  main- 
tained considerable  of  the  masculine  type.  She  never  showed  the 
slightest  disposition  to  menstruate.  She  Avas  asked  by  a  Avorthy 
man  to  marry,  but  she  was  afraid  to  do  so  without  advice,  kno^ving 


DISEASES   OF   THE   VAGINA.  Ifl3 

that  she  was  "  unlike  other  women."  She  sought  advice,  and  on  ex- 
.amination  there  was  found  atresia  of  the  vagina,  and  a])parentlj  the 
uterus  and  ovaries  were  rudimentary.  Nothing  could  be  done  to 
help  her.  She  took  up  nursing  as  a  profession,  and  has  succeeded 
remarkably  well.  This  case  is  briefly  given  in  order  that  this  variety 
may  be  contrasted  with  the  next  form. 

Atresia  associated  with  fully  developed  uterus  and  ovaries  may 
be  complete  or  incomplete.  Usually,  there  is  no  notice  taken  of  the 
deformity  until  puberty  arrives,  unless  the  attention  of  the  mother 
or  physician  is  directed  to  the  pelvic  organs  for  some  other  reason. 
There  are  no  symptoms  until  puberty.  Tlien  the  patient,  after  hav- 
ing undergone  the  changes  characteristic  of  the  period,  has  all  the 
symptoms  of  menstruation  without  the  flow. 

The  symptoms,  or  menstrual  molimen,  as  they  are  called  in  tbeir 
totality,  are  more  marked  than  in  normal  menstruation,  and  great 
pain,  fullness,  and  tenesmus,  come  on  during  the  period.  The  tirst 
■effort  at  menstruation  is  not  usually  attended  with  such  severe  suf- 
fering, but  each  succeeding  period  is  worse,  and  very  soon  the  evi- 
dences of  the  accumulated  fluid  become  tangible. 

Physical  Signs. — Inspection  of  the  parts  shows  a  complete  closure 
■of  the  vulva.  Combined  touch  with  a  straight  sound  in  the  bladder 
and  a  finger  in  the  rectum,  reveals  the  fact  that  in  absence  of  the 
vagina  the  rectal  and  vesical  walls  come  together,  and  are  thin  and 
■elastic.  If  the  vagina  is  present,  but  closed,  it  is  felt  between  the 
sound  and  finger  as  a  firm  cord.  When  the  uterus  is  distended  with 
menstrual  fluid,  the  accumulation  causes  a  tumor,  which  is  elastic  and 
-obscurely  fluctuating.  The  signs  of  partial  atresia  differ  according 
to  the  location  of  the  occlusion.  When  the  atresia  is  in  the  upper 
third  of  the  vagina  the  lower  portion  of  the  canal  ends  in  a  cul-de-sac. 
If  the  atresia  is  at  the  lower  third,  the  obstruction  is  found  below,  and, 
by  means  of  the  sound  in  the  bladder  and  the  finger  in  the  rectum, 
the  upper  portion  of  the  vagina  is  found  distended  with  menstrual  fluid. 

Causation. — Congenital  atresia  is  produced  by  some  arrest  of 
development  or  disease  during  embryonic  life.  When  it  is  acquired 
between  birth  and  j)uberty,  it  is  usually  due  to  acute  inflammation 
occurring  in  connection  with  some  constitutional  disease,  such  as 
scarlatina,  diphtheria,  or  measles. 

Gangrenous  vulvitis  and  vaginitis,  which  may  occur  in  the  course 
of  any  of  the  above-named  diseases,  may  also  terminate  in  atresia. 
I  have  seen  two  cases  of  partial  atresia,  caused  by  some  acute  inflam- 
mation during  the  course  of  typhoid  fever,  occurring  near  the  period 
of  puberty. 


104  DISEASES   OF  WOMEN. 

In  the  cases  which  have  been  acquired  after  puberty  and  child- 
bearing,  one  was  a  soldier's  wife,  who  was  confined  of  her  first  child 
at  a  military  post  on  the  frontier.  Her  labor  was  of  three  days' 
duration,  and  she  was  finally  delivered  by  craniotomy ;  there  was 
subsequent  sloughing  of  the  vaginal  walls,  and  consequent  atresia. 

Another  case  of  partial  atresia  was  caused  by  amputation  of  the 
cervix  for  cancer.  There  was  at  the  time  of  the  operation  deep  cau- 
terization of  the  vaginal  walls,  wdiich  resulted  in  atresia.  One  other 
case  was  caused  by  the  accidental  use  of  pure  carbolic  acid,  as  a  vag- 
inal injection.  In  this  case  the  adhesions  of  the  vaginal  walls  were 
not  very  firm,  and  the  canal  was  restored  by  operation,  but  there 
was  much  trouble  exj)erienced  in  preventing  the  recurrence  of  the 
atresia — a  constant  tendency  to  which  remained. 

Prognosis. — In  complete  atresia  there  is  great  diflBculty  in  tlie 
operation  for  its  relief,  and  a  constant  tendency  to  contraction  of 
the  parts ;  hence,  the  hope  of  complete  recovery  is,  to  say  the  least, 
very  limited. 

Treatment. — The  indications  are  to  restore  the  vagina  by  surgical 
means.  This  is  a  difficult  procedure,  and  one  that  is  not  very  suc- 
cessful in  all  cases.  The  difficulties  in  the  operation,  and  the  ulti- 
mate success,  depend  upon  whether  the  atresia  is  partial  or  complete. 
If  the  portion  of  the  vagina  which  is  closed  is  limited  to  a  third  of 
the  whole  canal,  reasonable  hope  of  success  may  be  entertained,  but 
I  doubt  if  the  vagina  was  ever  fully  restored  and  maintained  when 
complete  atresia  existed. 

When  there  is  associated  with  the  atresia  imperfect  development 
of  the  uterus  and  ovaries,  and  there  is  no  tendency  to  menstruation, 
treatment  is  not  indicated.  Such  malformed  subjects  often  live  quite 
comfortable  and  useful  lives. 

There  is  another  class  of  cases,  already  referred  to  in  treating  of 
absence  of  the  menstnial  function,  in  which  the  uterus  and  vagina 
are  rudimeutarv',  but  the  ovaries  are  well  developed.  In  these  there 
is  a  recurring  menstrual  molimen,  and  the  general  nervous  system 
may  become  greatly  deranged.  Ovaro-epilepsy  may  occur  under 
these  conditions.  The  removal  of  the  ovaries  might  become  neces- 
sary in  such  cases  in  order  to  arrest  the  inclination  to  menstruation, 
and  relieve  the  constitutional  disturbance  caused  by  such  unsuccessful 
efforts. 

The  following  is  a  description  of  Dupuytren's  operation  for 
atresia  of  the  vagina,  as  described  by  Courty,  with  the  modifications 
which  ]\[.  Puesch  has  added,  which  I  quote  from  the  work  of  Dr. 
Thomas : 


DISEASES   OF  THE   VAGINA.  105 

"  After  having  arranged  the  woman  in  a  convenient  position,  the 
bladder  is  emptied  by  means  of  a  male  catheter,  which  is  given  to 
an  assistant,  who  holds  it  turned  upward.  It  is  not  removed  during 
the  operation,  except  where  the  obliquity  of  the  part  would  render 
it  troublesome.  The  index-linger  of  the  left  hand  is  then  carried 
into  the  intestine  as  far  as  jDOSsible,  in  order  to  serve  as  a  guide  for 
the  bistoury  and  at  the  same  time  as  a  protection  to  the  rectum. 
After  these  preliminary  steps  the  operator,  placed  between  the  thighs 
of  the  patient,  makes  a  transverse  incision  at  the  center  of  the  obsta- 
cle, or  in  the  vulvar  orifice,  if  the  vagina  is  completely  wanting ;  if 
the  cellular  tissue  is  lax,  he  can  tear  with  his  finger,  the  sound,  or 
the  handle  of  the  bistoury  the  vesical  and  rectal  walls  till  he  reaches 
the  tumor ;  if  it  is  tense  or  too  resistant,  the  surgeon  dissects  by 
gentle  efforts,  separating  the  tissues  with  the  handle  or  the  finger 
rather  than  cutting  them,  and,  if  it  be  necessary,  breaking  them  down 
at  the  edges  with  a  button  bistoury.  In  each  case  he  proceeds  slowly 
and  carefully,  stopping  from  time  to  time  to  examine  with  the  finger 
and  be  certain  at  what  distance  those  organs  are  situated  which  it  is 
necessary  to  avoid.  When  the  canal  which  has  been  reopened  will 
admit  the  index-finger  easily,  and  when  a  more  distinct  perception 
of  fluctuation  announces  the  proximity  of  the  sanguineous  collection, 
the  operator  is  warranted  in  plunging  a  trocar  into  this,  and  the 
pouring  out  of  a  sirupy,  bro^vn  liquid,  like  the  lees  of  wine,  will 
show  that  the  end  has  been  reached.  The  pressure  upon  the  uterus 
is  then  stopped,  a  large  part  of  the  fluid  is  allowed  to  flow  away 
through  the  canula,  and  then,  substituting  for  this  instrument  a  per- 
forated sound,  the  operator  increases  the  size  of  the  opening  by  nu- 
merous incisions  upon  its  sides,  and  thus  renders  certain  the  final 
result.  Afterward  he  carries  a  gum-elastic  sound  into  the  uterine 
cavity,  and  throws  through  this,  but  with  very  httle  force,  several 
injections  of  warm  water.  The  dressing  having  been  finished,  the 
parts  are  sponged  and  dried,  and  the  patient  is  placed  in  bed,  pro- 
tected with  cloths,  so  as  to  prevent  the  bedding  from  being  soiled 
by  the  mucous  and  sanguinolent  discharges  which  flow  during  the 
first  days." 

To  keep  the  canal  open  after  this  operation  is  exceedingly  difii- 
cult ;  all  surgeons  testify  to  this  fact.  Many  things  have  been  tried 
to  accomphsh  this  object,  but  the  best  is  the  glass  plug  or  dilator  of 
Sims  (Fig.  57).  In  one  case — the  case  of  acquired  atresia  referred 
to  under  the  head  of  causation — I  found  that  the  glass  instrument 
caused  much  pain,  and  I  used  elm-bark  cut  in  fine  strips,  made  into 
a  roll  of  suitable  size,  and  moistened  with  carbohzed  water.     This 


106 


DISEASES   OF   WOMEN. 


Fig.  57. — Sims's  vaginal  dilator. 


was  removed  daily,  and,  as  it  expanded  after  being  introduced,  it 
answered  in  that  case  very  well. 

The  tendency  in  all  these  cases  is  to  contraction  and  return  of 
the  atresia  ;  in  fact,  I 
have  never  seen  a 
case  of  complete  atre- 
sia permanently  cur- 
ed. In  view  of  all 
these,  I  have  been 
guided  in  practice 
by  the  valuable  sug- 
gestions of  "West, 
The  following  is  from  his  work  on  "  Diseases  of  Women,"  page  34 : 

"  The  operation  for  atresia  is  performed  by  the  bistoury  or 
guarded  bistoury,  or  Pouteau's  trocar.  The  bistou)'y  is  to  be  gener- 
ally preferred.  Pouteau's  trocar  is  resorted  to  when  a  considerable 
part  of  the  lower  vagina  is  absent,  and  the  sac  is  punctured  some- 
times pretty  high  up  per  rectum.  This  operation  is  in  such  cases 
preferable  to  vain,  painful,  and  dangerous  attempts  to  bore  the  thin 
tissues  between  the  urethra  and  rectum  to  make  and  maintain  a  new 
vagina.  Such  a  proceeding  results  only  in  vexation.  It  is  far  better 
for  the  malformed  woman  to  discourage  all  hopes  of  maternity.  The 
artificial  j^assage  into  the  rectum  is  easily  kept  open,  and  the  men- 
stnial  Huid  runs  oft"  through  it." 


INFLAMMATORY   AFFECTIONS    OF    THE    VAGINA. 

Vaginitis. — The  vagina  is  seldom  if  ever  affected  with  idiojiathic 
inflammation ;  vaginitis,  therefore,  always  occurs  as  the  result  of 
some  speciflc  cause,  or  is  secondary  to  some  contiguous  inflammation, 
such  as  endometritis.  There  are  several  varieties  of  vaginitis.  Clas- 
sifled  according  to  the  intensity  and  duration  of  the  aft'ection,  there 
are  the  acute  and  chronic  forms ;  when  classified  according  to  the 
causation,  there  is  a  number  of  forms,  the  most  important  of  which 
are  gonorrhreal,  erythematous,  sometimes  called  eiysipelatous,  and 
diplitheritic.  As  a  rule,  the  inflammation  is  general,  involving  the 
whole  canal ;  occasionally  it  is  circumscribed,  and  then  it  is  found 
just  within  the  vulva,  or  else  at  the  u"i>per  part. 

J^athology. — Owing  to  the  anatomical  peculiarities  of  the  vagina 
it  is  not  suscej^tiblc  of  the  catarrhal  form  of  inflammation,  so  com- 
mon to  mucous  membranes  elsewhere.  From  the  fact  that  the  vag- 
inal mucous  membrane  resembles  in   structure  the  skin,  and  that 


DISEASES   OP   THE   VAGINA.  10 7 

there  are  few  mucous  follicles  found  in  it,  vaginitis,  in  its  pathology, 
is  more  like  dermatitis  than  like  the  ordinary  iuHammations  of  mu- 
cous membranes.  Congestion,  transudation  of  serum,  premature  ex- 
foliation of  the  ejDithelium,  and,  in  well-delined  cases,  the  formation 
of  pus,  are  the  characteristic  results  of  acute  vaginitis. 

In  the  subacute  form  there  is  less  congestion  and  less  pus,  other- 
wise the  inflammatory  lesions  are  the  same.  This  ma}'  all  be  more 
briefly  stated  in  another  form,  as  follows :  Vaginitis  occurs  either  as 
erythematous,  purulent,  or  exudative — never  as  purely  catarrhal. 

The  morbid  appearances  in  these  forms  differ.  Erythematous 
vaginitis  is  characterized  by  great  capillary  congestion,  which  gives 
the  intense  redness  of  this  form  of  inflammation  in  the  first  stage. 
Then,  as  the  disease  advances,  there  is  exfoliation  of  the  epithelium. 
Sometimes  the  epithelium  comes  off  in  thin  flakes,  resembling  in 
this  respect  the  exfoliation  of  the  cuticle  in  dermatitis.  This  leaves 
the  mucous  membrane  denuded  of  its  epithelium,  and  gives  a  glazed 
appearance  to  the  whole  canal.  During  this  time  there  may  be  a 
free  serous  secretion  and  some  pus  found,  but  these  are  not  profuse 
in  all  cases. 

In  purulent  vaginitis  the  lesions  are  the  same  as  already  described. 
In  the  exudative  forms  the  characteristic  lesions  are  present ;  the 
diphtheritic  membrane  as  in  diphtheria,  the  croupous  in  that  form 
of  inflammation. 

There  are  other  forms  of  vaginitis  mentioned  by  some  authors, 
but  they  are  peculiar  in  regard  to  causation,  while  in  tlieir  pathol- 
ogy they  do  not  differ  materially  from  those  described. 

Bymjptomatology . — The  symptoms  in  the  acute  form  are  a  feeling 
of  internal  heat  and  fullness.  These  increase  in  intensity,  and  pain 
in  the  vagina  and  uterus  come  on.  Vesical  and  rectal  tenesmus  are 
present  in  severe  cases,  and  urination  and  defecation  are  painful. 
The  urine  causes  violent  smarting  of  the  inflamed  parts  aliout  the 
vulva  w^th  which  it  comes  in  contact.  So  severe  is  the  pain  in  some 
cases  during  and  after  urination,  that  the  patient  resists  the  inclina- 
tion until  the  power  of  evacuation  is  lost,  and  there  is  retention. 

There  are  constitutional  disturbances  also.  kX  first  there  is  fever, 
and  following  that  loss  of  appetite  and  debility.  The  discharge  is 
profuse,  and  sero-purulent  in  character ;  it  causes  excoriation  of  the 
external  parts,  which  often  extends  to  the  limbs.  If  great  cleanli- 
ness is  not  observed,  the  discharge  decomposes  and  causes  a  very  dis- 
agreeable odor. 

In  the  subacute  and  chronic  forms  of  vaginitis  the  symptoms 
are  the  same  in  character,  but  less  in  degree ;  in  fact,  the  annoy- 


108  DISEASES   OF  WOMEN. 

ing  discbarge  is  the  only  symptom  observed  in  many  of  these  mild 
eases. 

Physical  Signs. — By  inspection  of  the  parts  when  the  labia  are 
separated  the  characteristic  discharge  can  be  seen  and  recognized. 
It  differs  from  that  of  vulvitis  in  being  less  tenacious.  The  mucous 
glands  about  the  vulva  give  to  the  discharge  of  vulvitis  a  cohesive- 
ness  which  is  not  found  in  that  of  vaginitis.  The  use  of  Siras's 
speculum  will  show  the  inflamed  appearance  of  the  membrane  and 
the  discharge  which  is  present. 

The  anterior  and  lateral  portions  only  of  the  walls  of  the  vagina 
are  seen  through  the  Sims  speculum,  but  by  watching  the  folding 
together  of  the  posterior  and  anterior  walls,  as  the  speculum  is  with- 
drawn, the  whole  canal  can  be  thoroughly  inspected. 

The  difference  betw^een  the  signs  of  acute  and  sub-acute  inflam- 
mation is  simply  in  the  intensity  of  the  congestion,  the  extent  of  the 
canal  involved,  and  the  quantity  and  character  of  the  discharge. 

To  distinguish  gonorrhceal  vaginitis  from  the  non-specific  forms 
the  microscope  alone  is  sufiicient.  When  there  is  a  question  regard- 
ing the  nature  or  the  cause,  specimens  of  the  discharge  should  be 
examined  for  the  gonococci. 

Causation. — There  is  a  predisposition  to  vaginitis  in  those  of 
delicate  health  and  strumous  diathesis,  but  it  is  not  marked. 

Judging  from  my  own  observations,  the  common  causes  of  vagi- 
nitis are  gonorrhosal  virus,  metritis,  especially  puerperal,  and  ery- 
thematous affections.  This  applies  to  the  acute  form  of  the  affec- 
tion. 

Sub-acute  and  chronic  vaginitis  may  be  caused  by  any  inflam- 
mation in  the  neighborhood  of  the  canal.  Dysentery,  for  example, 
causes  vaginitis  not  infrequently.  Different  fungi  have  been  credited 
with  causing  vaginitis,  but  this  is  not  well  settled.  When  it  occurs 
in  connection  with  the  eruptive  diseases  the  cause  is,  of  course,  the 
specific  morbid  material  which  produces  the  constitutional  disease. 

Prognosis. — With  proper  care  vaginitis  can  be  arrested  and  re- 
covery secured  without  any  permanent  lesions.  It  is  liable  to  re- 
cur if  caused  by  gonorrhosa. 

Sometimes  permanent  damage  is  done  to  the  canal  when  the 
vaginitis  is  due  to  any  of  the  eruptive  diseases  or  diplitheria. 

Treatment. — In  the  past,  treatment  of  vaginitis  has  consisted 
mainly  of  the  frequent  use  of  medicinal  douches.  The  agents  used, 
and  the  means  and  ways  of  using  them,  have  varied  greatly  with 
different  practitioners.  Very  recently  a  new  method  of  treatment 
has  been  brought  to  the  notice  of  the  profession  by  Dr.  Engelmann, 


DISEASES   OF   THE   VAGINA.  109 

of  St.  Louis.  His  method  he  terms  the  dry  treatment,  which  consists 
in  the  use  of  medicinal  powders  and  medicated  tampons.  A  number 
of  years  ago  I  tried  this  method,  in  an  imperfect  and  limited  way, 
in  the  treatment  of  vaginitis  among  the  insane,  and  obtained  ex- 
perience enough  to  know  that  it  is  of  great  value.  I  find  even  now, 
however,  that  while  using  certain  agents  in  powdered  form,  and  also 
the  tampon,  the  discharge  from  the  inflammation  and  the  powder 
used  lodge  in  the  folds  of  the  mucous  membrane,  and  that  it  is 
necessary  to  use  a  vaginal  douche  occasionally  in  order  to  make  the 
treatment  effective. 

In  acute  vaginitis  I  employ  what  may  be  called  a  mixed  treat- 
ment, using  the  medicinal  agents  and  powder  with  tampon,  and  oc 
casionally  employing  the  douche  in  the  following  way  :  After  cleans- 
ing the  mucous  membrane  thoroughly  with  a  douche  of  warm  water 
and  borax,  a  drachm  to  the  quart,  I  then  thoroughly  apply  sub- 
nitrate  of  bismuth  and  prepared  chalk,  equal  parts,  and  introduce  a 
tampon  of  borated  cotton,  the  tampon  being  so  arranged  as  to  thor- 
oughly keep  the  vaginal  walls  apart ;  at  the  end  of  twenty-four  hours 
the  tampon  is  removed,  and  any  accumulation  of  the  discharge  and 
powder  is  thoroughly  removed  and  the  tampon  replaced.  At  the 
end  of  the  next  twenty-four  hours  the  tampon  is  removed  and  the 
doLiche  of  borax  and  water  employed,  and  the  dry  treatment  re- 
peated. 

In  acute  cases  where  there  is  much  pain,  and  especially  if  due 
to  specific  cause,  I  employ  iodoform  in  place  of  the  bismuth.  If 
the  trouble  does  not  yield  promptly  to  this  treatment  I  give  up  the 
dry  dressing,  and  every  third  day  apply  to  the  entire  canal,  by  means 
of  the  atomizer  with  strong  pressure,  a  solution  of  nitrate  of  silver, 
one  grain  to  the  ounce,  or  sulphate  of  zinc,  one  half  grain  to  the 
ounce.  I  find  that  such  mild  solutions,  applied  with  considerable 
force  with  the  atomizer,  diffuse  the  application  very  thoroughly,  and 
produce  a  far  more  marked  effect  than  much  stronger  solutions  used 
as  a  douche. 

The  method  of  application  or  spraying  the  canal  is  as  follows : 
A  Sims's  speculum  is  introduced,  and  when  the  canal  is  distended 
by  pressure,  the  spray  is  thoroughly  applied  to  the  upper  portion  of 
the  canal  and  to  the  anterior  and  lateral  walls,  and  the  posterior  wall 
is  sprayed  as  tlie  speculum  is  gradually  withdrawn.  In  the  inter- 
vening days  between  these  applications  I  employ  daily,  or  t'^ace  a 
day,  a  vaginal  douche  of  a  solution  of  sulphate  of  zinc,  sixty  grains 
to  the  quart  of  warm  water. 

In  cases  that  can  not  be  so  carefully  watched  and  treated,  I  rely 


110  DISEASES  OF  WOMEN. 

almost  wholly  upon  the  siilphate-of-ziuc  solution,  used  as  a  vaginal 
douche  twice  a  day  at  first,  and  subsequently  once  a  day.  This  an- 
swers remarkably  well  in  a  great  majority  of  cases,  but  there  is  a 
constant  liability  to  miss  a  portion  of  the  canal,  especially  the  upper 
and  posterior  fornix.  To  overcome  this,  an  application  of  the  nitrate 
of  silver  or  sulphate  of  zinc  is  to  be  made  to  these  neglected  parts 
once  or  twice  a  week  through  the  speculum. 

This  simple  treatment  is  usually  sufficient  in  all  ordinary  cases, 
but  whenever  the  disease  is  specific  in  its  origin,  and  is  complicated 
with  urethritis  and  endometritis,  then  these  affections  should  be 
treated  simultaneously  in  the  ordinary  way. 

If  treatment  is  neglected  or  discontinued  too  soon,  the  vaginitis 
will  recur  in  a  very  short  time. 

Vaginismus. — Since  the  time  when  Sims  first  described  this  affec- 
tion and  its  treatment  it  has  been  considered  by  most  writers  as  a 
distinct  affection,  and  is  usually  classed  as  a  neurosis  of  the  vagina 
or  hymen.  In  all  the  cases  which  have  come  under  my  observation 
the  trouble  has  been  due  either  to  some  affection  of  the  muscles  of 
the  pelvic  fioor,  or  to  a  hypertesthesia  of  the  mucous  membrane  of 
the  vagina.  The  former  will  be  spoken  of  in  connection  with  in- 
juries of  the  pelvic  floor. 

Hypereesthesia  due  to  affections  of  the  other  pelvic  organs,  I  have 
always  looked  upon  as  a  symptom  of  the  preceding  disease  of  the 
utei'us,  rectum,  or  bladder.  Yiewing  the  subject  from  this  stand- 
point, little  need  be  said  about  it  in  this  connection.  The  removal 
of  the  affections  which  give  rise  to  it  is  the  chief  indication,  and  is 
generally  sufficient  in  the  way  of  treatment.  It  may  be  mistaken 
for  anal  fissure,  urethral  caruncle,  or  vaginitis. 

Occasionally,  it  is  necessary  to  give  relief  while  the  treatment  is 
being  employed  to  reniove  the  cause  ;  and,  in  those  cases  in  which  the 
cause  can  not  be  removed,  efforts  shcndd  be  made  to  relieve  the  hyper- 
sesthesia.    This  can  usually  be  done  by  the  judicious  use  of  cocaine. 

Neoplasms  of  the  Vagina. — Many  of  the  neoplasms  of  the  vagina 
are  the  same  in  character  as  those  found  elsewhere ;  as,  for  example, 
sarcoma,  carcinoma,  fibroma,  and  lipoma.     All  these  are  very  rare. 

The  diagnosis  and  treatment  of  these  neo]>lasms  are  based  upon 
the  same  principles  as  those  which  guide  the  j^ractitioner  in  dealing 
with  such  affections  when  located  in  other  parts  of  the  body. 

I  will,  however,  give  a  T)rief  account  of  some  of  the  more  com- 
mon neoplasms  of  the  vagina : 

Cysts  of  the  Vagina. — These  vary  in  size  from  that  of  a  buck- 
shot to  that  of  a  child's  head — one  case,  at  least,  being  on  record, 


DISEASES   OP   THE   VAGINA.  HI 

in  which  the  tumor  was  of  the  hitter  size,  and  so  seriously  interfered 
with  hibor  as  to  necessitate  the  evacuation  of  its  contents  before  the 
labor  could  proceed.  Nelaton  reported  a  case  in  which,  on  analysis, 
the  cyst  contents  were  found  to  be  made  up  of  water,  eighteen 
parts  ;  albumen,  one  part  and  a  half  ;  and  salts,  a  half  part.  Micro- 
scopical examination  has  shown  the  presence  of  epithelium,  pus, 
cholesterine,  nucleated  and  lymphoid  cells  in  these  cysts.  Occa- 
sionally blood  and  pus  are  found  in  the  contents. 

AYinckel,  who  has  examined  these  cysts  with  great  care,  states 
that  their  walls  are  made  up  as  follows  :  The  external  surface  is 
covered  with  the  ordinary  pavement  epithelium  of  the  vagina ;  the 
thickness  of  the  walls  varies  between  one  twenty -fifth  and  two  fifths 
of  an  inch — the  thinnest  portion  being  formed  of  connective  tissue 
alone,  the  thicker  with  the  addition  of  smooth  muscular  fibers.  The 
internal  surface  is  usually  perfectly  smooth,  but  may  show  papillae 
covered  with  epithelium,  which  in  the  majority  of  cases  is  cylindri- 
cal, more  rarely  simple,  or  stratified  pavement  epithelium,  or,  still 
more  rarely,  stratified  pavement  and  cylindrical  epithelium  in  the 
same  cyst. 

These  cysts  of  the  vagina  are  caused  in  some  cases  by  a  closing 
and  subsequent  distention  of  the  vaginal  glands.  They  may  also  be 
due  to  dilated  lymph-vessels,  to  oedema,  and  to  the  accumulation  of 
blood  after  an  injury.  C,ysts  most  frequently  have  their  origin  in 
distended  Gartner's  ducts.  This  has  been  clearly  pointed  out  by 
Amand  Routh  in  his  most  interesting  article  in  Volume  XXXY  of 
the  "  Transactions  of  the  Obstetrical  Society  of  London."  Their 
recognition  is  not  difiicult,  provided  that  a  careful  inspection  is 
made  of  the  vaginal  canal.  Their  treatment  is  exceedingly  simple. 
It  consists  in  emptying  them  by  an  incision  through  their  walls.  To 
prevent  refilling,  the  cyst  wall  should  be  removed  if  possible,  and 
the  wound  closed.  If  that  is  not  possible,  the  portion  of  the  cyst 
wall  left  should  be  destroyed  with  cautery  or  caustic,  and  the  cavity 
packed  with  gauze  to  cause  healing  by  granulation. 

The  following  case,  illustrative  of  this  form  of  vaginal  cyst,  I 
quote  from  Dr.  Routh's  article  : 

"  Miss  C.  C,  aged  twenty-five,  first  saw  me  in  1889  for  coccygo- 
dynia  and  bearing  down,  due  to  pelvic  congestion.  She  improved 
rapidly,  but  over- walked  herself  in  January,  1890,  and  for  a  few 
weeks  suifered  as  before.  Two  years  and  a  half  afterward — Xovem- 
ber,  1892 — she  consulted  me  again  for  pain  over  the  right  ovarian 
region,  and  a  profuse  yellow  watery  discharge,  which  was  occasion- 
ally offensive.     Walking  caused  great  pain  down  the  right  leg  and 


112  DISEASES  OF  WOMEN. 

in  the  right  side.  The  abdomen  was  somewhat  distended,  and  the 
muscles  resistent  over  the  right  half  of  the  abdomen.  Per  vaginam 
tlie  uterus  was  m^obile,  but  pushed  over  to  the  left  by  a  somewhat 
elastic  mass  on  the  right  side  of  the  pelvis,  situated  apparently  be- 
tween the  layers  of  the  broad  ligament.  Bimanually  this  mass  could 
be  felt  to  be  partly  mobile,  elastic,  tender,  and  separate  from  the 
uterus,  which  by  means  of  the  sound  could  be  moved  to  some  extent 
independently  of  the  broad-ligament  tumor. 

"  In  the  vaginal  wall,  running  from  the  base  of  the  right  broad 
ligament,  starting  from  a  spot  slightly  to  the  right  side  of  the  cer- 
vix, there  was  an  elastic  ridge,  somewhat  irregular  in  outline,  which 
passed  forward  and  toward  the  middle  line,  becoming  lost  a  little  to 
the  right  of  the  urethra,  about  three  quarters  of  an  inch  behind  the 
base  of  the  vestibule.  I  could  not  find  out  where  the  discharge 
came  from,  though  I  noticed  that  the  upper  part  of  the  vagina  was 
free  from  discharge,  while  the  vulvar  orifice  was  always  moist,  and 
soiled  by  a  somewhat  viscid,  yellowish,  offensive  secretion. 

"  A  fortnight  later  the  patient  suffered  severe  throbbing  pain, 
and  the  temperature  rose  nightly  to  101°  or  102°  F.  The  vaginal 
ridge  had  then  become  larger,  tenser,  and  more  elastic,  and  evi- 
dently contained  fluid  reaching  very  nearly  to  the  vaginal  outlet  in 
the  middle  line  of  the  vaginal  roof. 

"  In  a  few  days  the  portion  of  the  vaginal  cyst  near  the  cervix 
was  found  to  be  more  swollen,  being  about  the  size  of  a  thumb,  but 
the  rest  of  the  vaginal  ridge  seemed  to  consist  of  several  cysts,  ap- 
parently intercommunicating.  There  seemed  also  to  be  definite 
communication  between  the  vaginal  cyst  and  the  broad-ligament 
tumor,  from  the  fact  that  pressure  upon  the  vaginal  cyst  caused  its 
contents  to  pass  backward,  while  straining  or  coughing  immediately 
refilled  it. 

"  The  patient  went  into  a  nursing  home,  and  was  examined  under 
ether.  The  vaginal  cyst  was  then  found  to  be  collapsed  along  its 
whole  length  ;  the  broad- ligament  tumor  was  very  distinctly  made 
out,  and  was  thought  to  be  a  broad-ligament  parovarian  cyst,  the 
vaginal  cyst  being  presumably  a  patent  Gartner's  duct  communiciit- 
ing  with  the  cyst  cavity.  At  the  end  of  the  examination,  as  the 
patient  was  regaining  consciousness,  she  coughed,  and  bore  strongly 
down,  causing  a  quantity  of  yellowish  offensive  pus  to  come  out  of 
a  minute  hole  not  previously  seen,  just  beneath  and  to  the  right  of 
the  urethral  orifice  at  the  base  of  the  vestibule.  A  small  probe 
passed  down  this  al)normal  orifice  for  three  quarters  of  an  inch, 
and  the  passage  was  laid  ojien  as  a  rectal  fistula  would  be.     The 


DISEASES  OP   THE   VAGINA.  113 

openings  of  Skene's  ducts  just  within  the  urethral  orifice  were  quite 
perceptible. 

"  I  then  opened  the  main  vaginal  cyst  about  two  inches  up  the 
vagina,  but  w^as  not  able  to  pass  a  probe  for  any  distance  either 
backward  or  forward. 

"  Offensive  pus  continued  for  some  days  to  come  away  from 
both  of  these  places,  but  mainly  from  the  anterior  orifice  ;  indeed,  I 
do  not  think  I  really  opened  the  main  cyst  posteriorly  on  the  first 
occasion.  A  few  days  later  I  succeeded  in  passing  a  probe  along 
the  whole  canal  from  the  anterior  orifice,  and  subsequently  a  direc- 
tor ;  and,  under  ether,  freely  laid  open  the  vaginal  cyst  by  means  of 
a  Paquelin's  cautery  knife,  letting  out  much  pus,  which  welled  freely 
out  of  the  upper  end  of  the  incision  at  the  base  of  the  broad  liga- 
ment. 

"The  duct  thus  laid  open  was  lined  by  smooth  membrane,  but 
no  microscopic  examination  was  made. 

"  A  sound  passed  into  this  upper  opening  near  the  cervix  went 
a  distance  of  five  inches  upward  and  outv^^ard,  and  was  evidently 
inside  a  cyst  cavity  in  the  broad  ligament. 

"  The  opening  was  enlarged  to  admit  the  finger,  which  could  be 
passed  into  the  cyst  behind  the  vagina,  and  could  make  out  that  the 
lining  membrane  was  smooth,  and  that  the  cyst  was  between  the 
layers  of  the  broad  ligament.  Per  Tectum  the  examining  finger 
passed  well  behind  the  cyst  cavity,  and  could  then  detect  a  sound 
passed  into  the  parovarian  cyst  from  the  vagina.  The  cavity  was 
washed  out  with  iodized  water,  and  a  drainage  tube  inserted. 

"  For  nearly  five  weeks  the  purulent  fluid  continued  to  come 
away,  speedily  losing  its  offensive  odor  and  becoming  daily  more 
watei'y,  and  at  the  upper  end  the  sides  of  the  vaginal  cyst  tended  to 
unite  again  over  the  drainage  tube,  which  was  gradually  shortened 
and  finally  removed,  leaving  a  canal  in  the  vaginal  wall  about  an 
inch  long  (March,  1893)  on  the  right  side  of  the  cervix. 

"  liovember  7,  1893. — A  rut  or  trough  is  to  be  felt  in  the  vagi- 
nal wall  to  the  right  of  the  vaginal  portion,  leading  into  a  short 
canal  an  inch  long.  The  canal  now  only  admits  a  large  sound,  and 
ends  in  a  cul-de-sac.  It  is  lined  by  a  bright  red  membrane.  The 
uterus  lies  in  its  central  position,  and  nothing  abnormal  can  be  felt 
in  the  right  broad-ligament  region.  The  patient  feels  perfectly 
well. 

"  This  is  believed  to  have  been  a  case  of  distended  Gartner's  duct, 
where  the  contents  finally  suppurated.  It  is  probable  that  at  first 
the  vaginal  part  of  the  duct  was  impervious,  but  had  become  grad- 
9 


114  DISEASES   OF  WOMEN. 

ually  opened  up  by  the  pressure  of  the  contents  of  the  distended 
portion  in  the  broad  ligament  where  the  pain  first  began." 

Dr.  Routh  has  been  able  to  find  but  two  other  cases  of  associated 
broad-ligament  and  vaginal  cyst,  one  described  by  Watts  in  1881, 
and  a  second  by  Veit  in  1882.     J^hese  are  as  follows : 

"  Watts's  patient  had  a  vaginal  cyst  which  bulged  from  the  an- 
terior vaginal  wall  in  the  position  of  a  urethrocele.  The  urethra 
was,  however,  quite  normal. 

"  He  laid  open  the  cyst  per  vaginam^  and  to  his  surprise  was  able 
to  pass  a  probe  several  inches  without  the  slightest  resistance.  The 
probe  passed  to  the  patient's  left  side,  and  its  tip  was  easily  felt  at  a 
point  midway  between  the  umbilicus  and  the  left  anterior  superior 
iliac  spine.  Watts  thought  this  probe  had  penetrated  to  the  perito- 
neal cavity,  but  I  think  it  pretty  clear  that,  as  in  my  case,  it  was 
really  between  the  layers  of  the  broad  ligament,  where  there  was 
almost  certainly  some  distention  of  the  duct  not  noticed  at  the  time, 
as  it  doubtless  speedily  collapsed  when  the  vaginal  cyst  was  opened. 

"  Yeit's  case  (1882)  was  that  of  a  married  multipara,  aged  forty- 
seven,  who  had  a  large  vaginal  cyst,  which  made  micturition  diffi- 
cult, owing  to  pressure  upon  the  urethra.  The  cyst  bulged  out 
between  the  labia  majora  as  large  as  a  child's  head. 

"  The  uterus  was  pushed  over  to  the  left  by  a  tense  elastic  swell- 
ing in  the  right  broad  ligament,  which  clearly  communicated  freely 
with  the  vaginal  cyst. 

"  The  case  was  treated  by  incision  of  the  vaginal  cyst,  draining 
both  it  and  the  broad-ligament  cyst,  and  by  cutting  out  a  large  piece 
of  the  lining  membrane  of  the  vaginal  cyst  to  prevent  reclosure. 
Cholesterine  crystals  were  found  in  the  fluid.  The  epithelium  was 
flattened  in  type. 

"  The  finger  could  be  passed  into  the  broad-ligament  cyst,  and 
the  ovary  could  be  felt  on  its  posterior  and  outer  surface." 

Fibroma,  Myoma,  and  Fibromyoma. — These  growths  occur  but 
rarely.  Like  the  cysts  of  which  T  have  already  spoken,  they  vary 
very  much  in  size ;  some  being  so  small  as  only  to  be  recognized  by 
the  most  careful  examination,  while  others  may  be  so  large  as  to  in- 
terfere seriously  with  micturition  or  defecation,  or  even  to  so  dimin- 
ish the  caliber  of  the  pelvic  canal  in  pregnant  women  as  to  prevent 
the  delivery  of  the  child  through  the  natural  passage,  and  to  necessi- 
tate laparotomy.  These  tumors  are  readily  recognized  by  their  den- 
sity. If  there  is  any  doubt  in  the  mind  of  the  practitioner,  an  aspi- 
rating needle  will  at  once  exclude  a  cyst  or  an  abscess.  If  the  tumor 
attains  aiiy  considerable  size  so  as  to  interfere  with  any  of  the  func- 


DISEASES  OF   THE   VAGINA.  115 

tions  it  should  be  i*emoved  ;  or  if,  though  small,  it  is  increasing  in 
size,  this  would  constitute  sufficient  indication  for  its  removal.  This 
may  be  done  by  Paquelin's  cautery,  if  the  tumor  is  sufficiently  pedun- 
culated, or  if  not,  it  may  be  enucleated. 

Sarcoma. — This  is  so  rare  as  to  need  Init  the  simple  mention. 
Its  treatment  should,  of  course,  be  prompt  removal  as  soon  as  recog- 
nized. 

Carcinoma. — All  that  I  think  it  necessary  to  say  on  this  subject 
has  been  said  in  the  chapter  on  Cancer  of  the  Uterus,  to  which  the 
reader  is  referred. 


CHAPTER   VII. 

INJURIES    TO    THE    PELVIC    FLOOR    FROM    PARTURITION    AND    OTHER 

CAUSES. 

In  order  to  comprehend  fully  the  nature  of  the  injuries  to  the 
pelvic  floor  and  their  varied  and  important  pathological  relations,  it 
is  necessary  to  review  briefly  the  anatomy  and  physiology  of  this 
structure. 

The  pelvic  floor,  which  is  also  known  by  the  somewhat  indefinite 
name  of  perinseum,  comprises  the  tissues  which  together  occupy  the 
space  between  the  bones  of  the  pelvic  outlet.  It  is  composed  of 
muscles,  fascia,  areolar  and  elastic  tissues.  The  muscles,  which 
are  the  chief  element  in  the  structure  and  perform  its  function, 
have  their  origin  from  the  ischium,  the  pubes,  and  the  coccyx. 
From  these  points  they  extend  downward,  inward,  and  backward  to 
the  median  line,  and  are  united  to  the  terminal  ends  of  the  rectum 
and  vagina  and  to  each  other  from  the  opposite  sides. 

The  levator-ani  muscle  arises  from  three  points  :  the  first  sec- 
tion from  the  posterior  surface  of  the  os  pubis  on  each  side  of  the 
symphysis,  the  third  section  from  the  spine  of  the  ischium,  and  the 
second  or  middle  portion  from  the  tendinous  arc  swinging  between 
these  two  points,  this  thickening  of  the  obturator  fascia  being  called 
the  "  white  line."  The  three  parts  converge  to  be  inserted  into  the 
coccyx,  or  the  recto-coccygeal  raphe,  though  a  few  fibers  are  given 
off  to  the  vagina,  perineal  body,  and  sphincter  ani.  The  general 
course  of  the  muscle  is  backward  in  a  nearly  horizontal  direction. 
It  is  lined  by  the  anal  or  levator  fascia  beneath,  while  above  it  is 
attached  to  the  strong  recto-vesical  fascia.  According  to  Dr.  W.  W. 
Browning  (Medical  News,  June  12,  1S97)  the  first  part  also  has  its 
origin  from  the  posterior  layer  of  the  triangular  ligament,  where  it 
blends  with  the  obturator  fascia  along  the  descending  ])ubic  ramus. 
Fig.  58  shows  the  position  and  attachment  of  this  mnscle. 

The  transversus-j)erinji'i  muscle  arises  fi'om  the  ramus  of  the 
ischium,  and  passes  across  to  the  median  line,  where  it  joins  its  fel- 
low of  the  opposite  side.     The  coccygeus  arises  from  the  spine  of 

116 


INJURIES  TO   THE   PELVIC   FLOOR.  117 

the  ischium,  and  is  inserted  into  the  side  of  the  lower  part  of  the 
sacrum  and  side  and  front  of  the  coccyx.  It  is  understood,  of  course, 
tliat  there  are  two  of  each  of  the  muscles  thus  far  described,  one  on 
each  side.     The  bulbo-cavernosus  muscle  can  be  most  easily  traced 


Fig.  58. — The  levator  ani,  seen  from  the  right  after  removal  of  much  of  the  ischium. 
Lp,  first  section  arising  from  the  rear  of  the  pubes ;  Lr,  second  part  arising  from 
the  fascia,  or  white  line ;  Li,  third,  or  ischial  portion.  The  sphincter  surrounds  the 
anus,  and  is  attached  to  the  coccyx. 

by  taking  as  its  orio-in  the  space  between  the  sphincter  ani  and  the 
orifice  of  the  vagina.  From  this  point  its  two  halves  pass  upward, 
one  on  each  side  of  the  vagina.  The  upper  anterior  end  of  each  slip 
of  muscle  divides  into  three  parts,  which  are  inserted  as  follow^s  :  One 
into  the  lower  surface  of  the  corpus  cavernosum  of  the  clitoris,  a 


118 


DISEASES  OF  WOMEN. 


second  into  the  posterior  portion  of  the  bulb,  and  the  third  unites 
with  its  fellow  of  the  opposite  side  in  the  mucous  membrane  of  the 
vestibule  ;  and  all  of  them  are,  through  tiie  medium  of  tendon  and 
fascia,  connected  to  the  pubic  bones.  If  this  muscle  is  traced  from 
above  downward  to  the  center  of  the  pelvic  floor,  it  will  be  seen  to 


Fig.  59. — The  muscles  of  the  pelvic  floor ;  on  one  side  the  superficial  muscles,  on  the 
other  the  three  parts  of  the  levator  (semi-diagrammatic).  The  ischio-rectal  fascia  is 
shown  beyond  the  nmscle. 

have  an  origin  and  insertion  like  that  of  the  anterior  libers  of  the 
levator  ani  ;  hence  the  bulbo-cavernosus  and  levator  ani  may  be  con- 
sidered as  one  muscle.  This  view  is  justifiable  from  the  fact  that 
they  also  contract  together,  having  a  similar  function. 

The  sphincter-ani   muscle,  which  has  a  function  peculiarly  its 


INJURIES   TO   THE   PELVIC   FLOOR. 


119 


own,  is  closely  united  to  all  the  other  muscles  of  the  pelvic  floor  by 
uii  interlacing  of  the  muscular  flbers  and  by  tendinous  and  fascial 
attachments.  This  muscle  arises  from  the  end  of  the  coccyx,  and 
divides  to  surround  the  end  of  the  rectum,  while  its  deeper  fibers 
are  inserted  in  the  tendinous  raphe  in  the  median  line  between  the 
rectum  and  vagina.  The  superficial  fibers  of  this  muscle  are  circu- 
lar, and  attached  to  the  integument. 

Taking  the  muscles  of  the  pelvic  floor  in  the  aggregate,  they 
form  one  complete  diaphragm  of  muscular  tissue  which  fills  the  pel- 


FiG.  60. — Diagramtnatic  sagittal  section  of  the  female  pelvis.  U,  uterus ;  R,  rectum ;  S, 
symphysis ;  P,  perineal  body ;  B,  is  beneath  bladder.  This  is  the  position  of  the 
uterus  when  the  bladder  is  moderately  full. 


vie  outlet.  By  this  arrangement  the  rectum  and  vagina  are  held  in 
position,  and  their  terminal  ends  controlled  in  the  performace  of 
their  functions.  The  muscular  attachment  of  the  muscles  and  va- 
gina is  in  part  shown  by  the  preceding  figures,  58  and  59. 

The  normal  elevation  of  the  pelvic  floor  is  illustrated  by  Fig.  60. 


120  DISEASES   OF   WOMEN. 

This  position  of  the  pelvic  floor  and  the  relations  of  the  rectum 
and  vagina  should  be  noted  because  they  become  changed  in  most 
of  the  injuries  of  this  structure. 

The  muscles  of  the  pelvic  floor  are  surrounded  by  the  deep  and 
superficial  fascia,  which  in  some  parts  becomes  ligamentous  in  char- 
acter;  for  example,  the  ischio-perineal  ligament — that  dense  portion 
of  the  fascia  which  stretches  from  one  side  to  the  other  through  the 
space  between  the  rectum  and  vagina.  This  fascial  structure  accom- 
panying the  muscles  is  characteristic  of  all  muscular  structures  which 
have  to  afford  continuous  sustaining  power,  like  the  muscles  of  the 
back,  of  the  neck,  abdomen,  and  thigh. 

Function. — These  anatomical  facts  regarding  the  floor  of  the  pel- 
vis suggest  that  its  functions  are  to  sustain  the  rectum  and  vagina, 
and  to  aid  in  their  functions.  The  arrangement  of  the  muscles  is 
such  that  they  close  by  sphincteric  action  the  terminal  ends  of  the 
rectum  and  vagina,  yet  also  permit  the  distention  of  their  orifices 
during  the  acts  of  parturition  and  evacuation  of  the  rectum.  When 
pressure  is  made  downward  by  any  body  in  the  rectum  or  vagina, 
the  levator  muscles  act  to  draw  the  orifices  of  these  canals  upward, 
and  hence  supply  a  resisting  force  to  the  downward  pressure  which 
effects  dilatation  of  the  vagina  and  rectum.  This  action  of  the  mus- 
cles in  resisting  downward  pressure  is  well  demonstrated  during  par- 
turition. AYhen  the  child's  head  presses  upon  the  floor  of  the  pel- 
vis, the  muscles,  by  retraction,  distend  the  sphincter  ani  to  a  great 
extent.  The  dilatation  of  the  vagina  is  produced  by  a  more  passive 
giving  way  to  the  forces  above,  and  yet  the  muscles  exert  a  well- 
defined  power  in  retracting  that  portion  of  the  pelvic  floor.  This 
function  of  the  muscles  should  be  noted  because  it  enters  into  the 
mechanism  of  most  of  the  injuries  to  be  discussed.  Tiegarded  as  a 
mechanical  structure,  the  pelvic  floor  resembles  a  diaphragm  com- 
posed of  muscles  and  fascia  which  close  the  pelvic  outlet.  Its  bor- 
ders are  attached  to  the  bony  walls  of  the  pelvis,  and  it  is  held 
at  its  proper  elevation  by  strong  fascia  and  the  levator-ani  muscle. 
Its  mechanism  is  based  upon  the  principles  of  the  suspension 
bridge,  the  anchorage  being  represented  l>y  the  pelvic  bones,  the 
floor  representing  the  bridge  and  the  levator-ani  muscle  with  the 
powerful  fascial  layers  corresponding  to  the  sustaining  cables  (see 

Fig.  r,i). 

This  brief  statement  i-egarding  the  function  of  the  ])elvic  floor 
embodies  the  essential  points  in  its  chief  offices.  There  remains 
something  to  be  said  regarding  its  relations  to  the  pelvic  organs. 

Up  to  the  present  time  the  attention  given  to  this  subject  by 


INJURIES   TO   THE   PELVIC   FLOOR. 


121 


gynecologists  has  been  almost  wholly  confined  to  laceration  of  the 
so-called  perineal  body — an  injury  frequently  seen,  but  not  by  any 
means  the  only  one  that  occurs  to  these  parts.  This  concentration 
of  attention  on  one  portion  of  the  subject  has  given  rise  to  great 
diversity  of  opinions  regarding  the  function  of  the  perinseum  and 


Fig.  61. 

its  relations  to  the  displacements  of  the  pelvic  organs,  one  party  to 
the  controversy  believing  that  the  perineal  body  has  much  to  do 
with  sustaining  the  pelvic  organs  in  position,  the  other  holding  that 
it  has  very  little  power  in  this  respect.  Without  summing  up  at 
great  length  the  arguments  on  both  sides,  the  facts  bearing  on  the 
practical  side  of  the  subject  may  be  briefly  stated. 

In  all  injuries  of  the  pelvic  floor  which  impair  its  supporting 
function  to  any  extent,  prolapsus  of  the  pelvic  organs  will  follow  in 
time,  except  in  three  conditions  : 

1.  Where  the  injury  is  compensated  for  by  the  muscles  (which 
still  maintain  their  attachment  to  the  vagina  and  rectum)  drawing 
the  remaining  portion  of  the  pelvic  floor  upward,  forward,  and 
toward  the  pubes,  thereby  closing  the  vaginal  orifice  and  supporting 
the  pelvic  organs. 

2.  Where  by  reason  of  some  intra-pelvic  inflammation  the  organs 
have  become  fixed  by  adhesions  ;  and, 

3.  Where  the  patient  is  abundantly  supplied  with  adipose  tissue, 
and  takes  very  little  active  exercise. 

Excepting  under  the  circumstances  here  named,  prolapsus  of  the 
pelvic  organs  invariably  occurs  after  important  injuries  of  the  pelvic 
floor.  The  displacement  does  not  follow  the  injury  immediately, 
but,  as  a  rule,  comes  on  slowly.  This  conclusion  has  been  arrived  at 
from  a  large  number  of  clinical  observations,  and  it  helps  to  defi- 
nitely settle  the  question  regarding  the  value  of  the  pelvic  floor  as 
a  means  of  support  for  the  pelvic  organs.  From  these  facts  one 
may  obtain  the  key  to  the  differences  of  opinion  which  have  been 


122  DISEASES   OF  WOMEN. 

held  by  gynecologists  regarding  the  functions  of  the  pelvic  floor. 
Those  who  believe  that  it  plays  a  secondary  part  in  maintaining  the 
pelvic  organs  in  position  argue  that  there  are  anatomical  structures 
which  sustain  the  pelvic  organs  in  place  without  aid  from  the  pel- 
vic floor,  and,  in  proof  of  this,  point  to  the  fact  that  the  removal 
of  the  pelvic  floor  is  not  followed  by  displacement  of  the  pelvic 
organs.  This  is  often  seen  in  cases  in  which  lacerations  sufficient 
to  largely  impair  the  function  of  the  pelvic  floor  have  existed  for 
years  in  women  in  active  life  without  the  occurrence  of  prolapsus 
of  the  pelvic  organs.  And,  more  than  all  this,  it  is  said,  prolapsus 
of  the  pelvic  organs  occurs  where  there  is  no  apparent  injury  of 
the  pelvic  floor — i.  e.,  no  laceration  of  the  perina^um.  The  fallacies 
of  this  argument  are  that,  although  the  pelvic  oi-gans  are  held  in 
position  by  supports  that  are  sufficient  to  resist  ordinary  taxation  for 
a  given  time,  they  are  not  able  to  do  so  under  extraordinary  pressure 
for  any  length  of  time  unaided  by  the  pelvic  floor. 

Again,  the  cases  cited  in  which  prolapsus  does  not  occur  when 
the  perineum  is  lacerated  belong  to  one  of  the  three  exce])tional 
states  which  I  have  already  given. 

And,  finally,  the  cases  in  which  there  is  prolapsus  while  the  pelvic 
floor  appears  to  be  uninjured  are,  as  a  rule,  cases  of  mistaken  diag- 
nosis, the  floor  of  the  pelvis  being  i-eally  imperfect,  although  not 
apparently  so  on  examination  by  the  sense  of  sight  alone.  Some 
observers  look  for  a  laceration  of  the  perinteum  by  inspection  of  its 
mucous  and  tegumentary  surfaces,  and,  if  injury  to  these  surfaces  is 
not  found,  they  pronounce  the  pelvic  floor  perfect,  while  the  fact  is 
that  laceration  of  the  perinannn  in  the  median  line  is  only  one  of 
many  injuries  of  the  pelvic  floor  which  render  it  functionally  imper- 
fect. But  granting  that  the  pelvic  floor  takes  no  part  in  supporting 
the  pelvic  organs  under  ordinary  taxation,  it  certainly  aids  in  doing 
so  in  case  there  is  extraoidinary  downward  pressure  from  lifting 
lieavy  weights,  violent  coughing,  and  the  like.  Again,  when  the 
pelvic  floor  is  injured — say  l>y  laceration — and  loses  the  power  to 
support  itself  and  the  vagina  and  rectum,  prolapsus,  esj)ecially  of  the 
vagina,  occurs.  This  causes  a  dragging  upon  the  pelvic  organs  wliich 
in  due  time  will  cause  them  to  descend.  In  view  of  these  well-known 
facts,  the  most  enthusiastic  advocate  of  the  independent  supports  of 
the  pelvic  organs  must  admit  that  the  pelvic  floor  is  at  least  indi- 
rectly concerned  in  su])]K)rting  the  structures  above  it. 

The  injuries  of  the  ]U'lvic  floor  are  of  two  classes  : 

1.  Lacerations  of  the  pelvic  floor  in  the  median  line. 

2.  Laceration  of  the  levator-ani  muscle  and  separation  of  the 


INJURIES   TO   THE   PELVIC   FLOOR.  123 

muscular  coat  of  the  vagina  from  the  pelvic  floor.  This  injury  is 
an  internal  transverse  laceration. 

The  flrst  class  is  divided  into  lacerations  extending  from  the 
vulva  down  to  the  sphincter-ani  muscle  ;  subcutaneous  separation  of 
the  muscles  and  fascia;  and  lacerations  extending  from  the  vulva 
into  the  rectum,  involving  the  sphincter  ani  and  less  or  more  of  the 
recto-vaginal  septum. 

The  tirst  of  these — laceration  of  the  pelvic  floor  in  the  median 
line — is  the  injury  most  frequently  sustained  during  parturition. 
Several  degrees  of  this  injury  are  described  by  authors,  but  in  re- 
gard to  the  pathology  and  treatment  there  are  only  two  which,  in 
this  connection,  require  attention  :  the  one  which  extends  through 
the  muscles  of  the  anterior  portion  of  the  pelvic  floor — that  is,  from 
the  vulva  to  the  sphincter-ani  muscle — and  the  other  which  extends 
through  the  sphincter-ani  muscle  and  into  the  rectum.  The  former  of 
these  is  the  injui-y  which  is  most  frequently  recognized,  and  is  there- 
fore presumed  to  occur  most  frequently,  although  this  point  is  not  yet 
settled.  Certainly  it  is  the  least  grave  in  its  consequences  if  properly 
cared  for,  because  it  is  the  most  easily  remedied  by  surgical  treatment. 

In  its  simplest  form  the  laceration  extends  through  the  mucous 
membrane  of  the  vagina,  the  integument,  and  the  junction  or  union 
of  the  bulbo-cavernosus  with  the  transversus-perinsei  muscle,  a  few 
fibers  of  the  levator  ani  and  the  fascia,  elastic  and  areolar  tissues 
which  constitute  the  perineal  body. 

AVhen  this  injury  is  uncomplicated  with  laceration  of  the  muscles 
of  the  pelvic  floor  elsewhere  than  at  the  median  line,  the  separated 
ends  of  the  muscles  involved  in  the  rupture  still  retain  their  union 
with  the  divided  side  of  the  perineal  body  and  with  each  other.  This 
is  very  clearly  shown  by  the  fact  that  the  bulbo-cavernosus,  trans- 
versus  perinsei,  and  anterior  fibers  of  the  levator-ani  muscles  hold 
the  separated  sides  of  the  perineal  body  and  the  posterior,  unin- 
jured portion  of  the  pelvic  floor  upward.  At  the  same  time  that 
the  posterior  portion  of  the  pelvic  floor  is  maintained  at  its  nor- 
mal elevation,  it  is  often  brought  forward  to  compensate  for  the 
loss  of  support  caused  by  the  laceration.  This  compensation  does 
not  occur  in  all  cases,  but  usually  does  so  unless  there  is  damage 
done  to  the  muscles  other  than  at  the  median  rupture  alone.  I  have 
observed  in  some  cases  suflieient  drawing  forward  to  lessen  the  dis- 
tance between  the  meatus  urinarius  and  anus  very  perceptibly.  This 
is  familiar  to  all  who  have  studied  the  subject  with  a  view  to  operat- 
ing, from  the  fact  that,  in  order  to  estimate  the  depth  of  the  lacera- 
tion, to  determine  how  extensive  the  vivifying  of  tissue  need  be,  it 


124  DISEASES  OF   WOMEN. 

is  necessary  to  retract  the  posterior  portion  of  the  pelvic  floor  with 
the  tinger  or  sound  in  order  to  press  the  rectum  or  anus  backward 
into  its  place.  This  compensation  prevents  prolapsus  of  the  pelvic 
organs  for  a  long  time,  in  some  cases  for  many  years,  and  is  one  rea- 
son why  rupture  of  the  perineal  body  is  not  always  followed  by  pro- 
lapsus uteri.  In  this  condition  the  vulva  is  not  enlarged  from  dis- 
tention by  the  partially  inverted  vaginal  walls,  nor  is  the  uterus 
necessarily  displaced.  Many  such  cases  are  seen  ajnong  patients 
who  seek  relief  for  other  affections,  but  have  no  symptoms  which 
can  be  traced  to  tlie  laceration,  except  occasional  pain  in  the  scar 
tissue  in  the  injured  part. 

In  cases  of  long  standing  the  posterior  vaginal  wall  becomes 
prolapsed.  Tiiis  condition  has  been  described  as  rectocele.  The 
diagnosis  is  made  by  inspection. 

The  second  form  of  injury  given  in  the  classification  is  subcu- 
taneous separation  of  the  nmscles  and  fascia  in  the  median  line, 
usually  limited  to  the  transversus  perinsei  muscle  and  fascia,  but  in 
rare  cases  involving  the  sphincter-ani  muscle. 

Years  ago,  when  I  first  called  attention  to  this  subject,  I  was  not 
aware  that  the  sphincter  ani  was  ever  involved  in  this  form  of  in- 
jury, but  I  have  seen  since  then  at  least  three  cases  in  which  the 
sphincter  ani  was  lacerated  completely  while  the  integument  and 
mucous  membrane  of  the  vagina  remained  uninjured.  The  evi- 
dences that  my  observations  were  correct  are  that  there  was  incon- 
tinence, the  integument  on  either  side  was  depressed  where  the 
lower  fibers  of  the  retracted  muscles  had  drawn  it  inward,  and  the 
most  careful  examination  proved  l)eyond  a  question  that  the  integu- 
ment had  never  been  lacerated.  I  am  aware  of  the  fact  that  a  com- 
plete laceration  in  the  median  line  may  unite  by  first  intention,  leav- 
ing the  sphincter  ani  ununited,  and  that  the  scar  may  be  so  faint  as 
to  be  easily  overlooked,  but  in  the  cases  I  have  referred  to  I  am  posi- 
tive fmm  my  own  examination,  and  that  of  my  associates,  that  no 
such  injury  to  the  integument  ever  occurred.  Furthermore,  I 
found  in  operating  that  when  the  integument  was  divided  some 
thickening  of  the  cellular  tissue  was  apparent,  due  no  doul)t  to  a 
reparative  exudate  which  occurred  at  the  time  of  the  injury.  I  also 
found  the  ends  of  the  muscle  far  apart,  the  lacerated  ends  being 
completely  healed  over  by  natural  ])rocesses.  In  looking  back  I 
recall  several  more  cases  of  this  kind,  but  not  having  studied  them 
witli  sufticicnt  care,  they  are  not  available  for  my  present  purpose. 

The  mucous  membrane  of  the  vagina  and  the  skin  covering  the 
perinaeum  remain  normal,  but  the  transversus-perinaei  muscles  aie 


INJURIES  TO   THE   PELVIC   FLOOR.  125 

torn  apart  in  tlie  median  line.  The  bull>o-cavernosus  muscles  are 
separated  from  their  insertion  at  the  center  of  the  perinaeum,  and 
possibly  some  of  the  libers  of  the  levator-ani  muscle  ai"e  also  lacer- 
ated. There  is,  in  short,  a  complete  laceration  of  the  deeper  struc- 
tures of  the  perinseum,  the  skin  and  mucous  membrane  alone  re- 
maining uninjured.  The  result  of  this  injury  is  falling  of  the 
pelvic  floor,  and  usually  prolapsus  of  the  pelvic  organs.  The  func- 
tion of  the  pelvic  floor  is  destroyed  or  impaired  as  iu  the  injury 
first  described. 

I  believe  that  this  condition  has  generally  been  mistaken  for 
functional  imperfection  of  the  perinseum,  or  relaxation,  as  it  has 
been  called.  The  fact  is,  that  it  is  a  well-defined  anatomical  lesion, 
which  can  be  demonstrated  quite  easily  by  passing  the  finger  into 
the  vagina  and  pressing  downward  and  outward.  In  this  way  the 
absence  of  the  muscles,  fascia,  and  connective  tissue  is  discovered. 
It  is  found  also  by  this  examination  that  all  muscular  resistance  is 
lost  in  the  parts.  Again,  while  the  index-finger  is  in  the  vagina  the 
parts  anterior  to  the  sphincter-ani  muscle  can  be  grasped  between 
the  finger  and  tlmmb,  which  will  show  that  where  the  perineal  body 
should  be  there  is  only  skin  and  posterior  vaginal  wall.  There  is 
still  another  method  of  examination,  and  perhaps  the  most  critical 
one — that  is,  to  pass  one  index-finger  into  the  vagina  and  the  other 
into  the  rectum,  when  it  will  be  found  that  the  only  resisting  mus- 
cular tissue  felt  between  the  two  fingers  is  the  sphincter  ani. 

These  examinations  by  the  touch  are  quite  sufficient ;  but  if  fur- 
ther evidence  is  desired,  it  may  be  obtained  by  trying  to  excite  con- 
traction of  the  muscles  which  act  as  a  sphincter  vaginae.  This  can 
be  done  by  the  interrupted  electric  current,  or  by  irritating  the  labia. 
In  making  a  vaginal  examination,  one  can  observe  how  actively 
the  muscles  of  the  pelvic  floor  contract  and  close  the  introitus  vagi- 
nae in  the  normal  state;  but  in  this  injury  no  such  contraction  oc- 
curs, nor  can  it  be  produced  by  pricking  the  labia  with  a  needle,  or 
by  any  such  means  used  to  excite  reflex  action. 

In  case  the  levator-ani  muscle  remains  intact,  the  posterior  por- 
tion of  the  pelvic  floor  remains  in  its  normal  position,  except  that 
the  end  of  the  rectum  may  be  displaced  backward,  but  it  rarely  is,  as 
a  rule,  because  the  vagina  and  uterus  are  not  prolapsed.  The  coun- 
terpart of  this  lesion  is  often  seen  in  cases  that  have  been  operated 
upon  with  the  intention  of  restoring  the  pelvic  floor  or  perinaeum, 
the  operation  having  failed  in  its  object.  Union  of  the  skin  and 
mucous  membrane  is  obtained,  but  the  muscles  are  not  united,  and 
hence,  although  upon  removing  the  sutures  the  result  is  pronounced 


126  DISEASES  OF  WOMEN. 

to  be  perfect,  and  to  the  superficial  observer  appears  to  be  so,  the 
muscular  function  of  the  pelvic  floor  has  not  been  restored,  and  the 
operation  is,  in  fact,  a  complete  failure. 

When  the  two  forms  of  injury  just  described  have  existed  for  a 
long  time  prolapsus  of  the  vaginal  vi^alls  takes  place.  The  posterior 
vaginal  wall  is  most  frequently  displaced  and  is  usually  described 
as  a  rectocele,  but  that  is  incorrect,  as  will  be  pointed  out  in  discuss- 
ing transverse  internal  lacerations. 

The  third  form  of  injury  in  the  njedian  line  extends  from 
the  vulva  into  the  rectum,  and  includes  in  the  solution  of  continu- 
ity the  sphincter-ani  muscle  and  less  or  more  of  the  recto-vaginal 
septum. 

Rupture  through  the  sphincter  ani  is  the  most  unfortunate  of  all 
injuries  of  the  pelvic  floor,  owing  to  the  incontinence  which  follows. 
The  unhappy  subjects  of  this  accident  are  debarred  from  taking 
much  active  exercise,  and  usually  avoid  society.  Strange  as  it  may 
appear,  they  do  not  all  suffer  from  prolapsus  of  the  pelvic  organs ; 
in  fact,  I  think  that  prolapsus  following  this  injury,  to  any  great 
degree  at  least,  is  the  exception.  This  is,  no  doubt,  due  to  the  fact 
that  such  patients  are  unable  to  do  much  walking  or  standing,  and 
therefore  the  pelvic  organs  are  not  submitted  to  much  downward 
pressure.  It  might  be  supposed  that  relief  from  this  distressing 
condition  would  be  sought  before  sufficient  time  had  elapsed  for 
prolapsus  to  occur,  but  this  is  not  always  the  case,  for  I  have 
seen  several  such  injuries  of  many  years'  standing,  and  yet  there 
was  very  little  displacement.  There  is  indeed  very  little  falling 
of  the  pelvic  floor  or  of  its  divided  sides.  This  is  accounted  for 
by  the  fact  that  the  laceration  extends  through  the  greater  por- 
tion of  the  pelvic  floor,  leaving  little  remaining  to  settle  down- 
ward. In  most  cases  the  two  halves  of  the  floor  are  held  well  up 
in  position  by  the  muscles  which  are  attached  to  them.  When  the 
laceration  is  through  the  sphincter-ani  muscle  only,  and  does  not 
extend  upward  into  the  anterior  wall  of  the  rectum  and  the  poste- 
rior wall  of  the  vagina,  there  is  a  little  control  of  the  rectum  still 
retained. 

This  retaining  power  is  sometimes  favored  by  a  band  of  scar  tis- 
sue, which  lies  between  the  upper  fibers  of  the  divided  sj)liincter, 
and  gives  a  fixed  point  toward  which  the  muscle  can  contract  in  an 
imperfect  way.  There  is  usually  ]>r()lHpsus  of  the  mucous  membrane 
of  the  rectum  in  cases  of  long  standing,  and  the  prolapsus  is  almost 
always  greater  if  the  wall  of  the  vagina  and  rectum  are  also  lacer- 
ated to  any  great  extent. 


INJURIES   TO   THE   PELVIC   FLOOR. 


m 


Injuries  of  the  second  class,  which  are  transverse,  and  have  been 
described  as  internal  lacerations,  consist  in  laceration  of  the  anterior 
fibers  of  the  levator-ani  muscle  and  fascia,  and  this  is  usually  attended 
with  separation  of  the  muscular  layer  of  the  vaginal  wall  from  the 
pelvic  floor.  In  some  cases  the  laceration  is  complete,  involving  the 
mucous  membrane  as  well  as  the  muscular  coat  of  the  vagina,  and  in 
very  rare  cases  the  laceration  reaches  upward  and  outward  as  far  as 
the  laceration  of  the  levator-ani  muscle  extends,  but  as  a  rule  the 
laceration  of  the  levator  ani  is  subcutaneous — that  is  to  say,  not 
attended  with  laceration  of  the  mucous  membrane  of  the  vaginal 
wall.  The  injury  of  this  muscle,  I  believe,  was  first  described  in  my 
early  writing  on  the  subject,  but  if  this  is  an  unjust  claim  on  my  part 
I  shall  be  happy  to  have  it  corrected. 

The  pathological  changes  which  ultimately  take  place  in  the  trans- 
verse lacerations  are  :  A  marked  sagging  of  the  pelvic  floor,  which  in 
itself  may  be  perfectly  normal  in  structure.  This  sagging  is  appar- 
ent upon  inspection,  and,  as  I  have  elsewhere  pointed  out,  the  diag- 
nosis of  this  lac- 
eration is  made  ^  ^  /" 
from  the  fact  that 
under  stimula- 
tion the  levator- 
ani  muscle  fails 
to  perform  its 
function.  The 
action  of  this 
muscle  is  to  a 
large  extent  vol- 
untary, and  this 
voluntary  power 
is  lost  and  stimu- 
lation fails  to  call 

it  into  action.  Of  course,  the  continuation  of  this  sagging  gives 
rise  to  or  permits  prolapsus  of  the  vaginal  walls,  uterus,  and  bladder. 
Rectocele  is  also  said  to  follow  in  this  injury,  and  possibly  it  may 
in  rare  cases,  but  I  am  fully  assured  from  careful  observation  that 
the  so-called  rectocele  is  not  a  rectocele  at  all,  but  a  prolapsus  of  the 
vaginal  wall  and  a  varicose  condition  of  the  veins  lying  between  the 
vagina  and  the  rectum  just  within  or  above  the  pelvic  floor.  This 
I  have  been  able  to  demonstrate,  in  a  vast  majority  of  cases,  by  an 
examination  which  proved  that  there  was  no  rectal  diverticulum 
pointing  toward  the  vulva,  and  that  pressure  upon  the  so-called  rec- 


FiG.  62. 


-The  so-called  rectocele,  being  a  prolapse  of  the  vaginal 
wall,  with  varicose  veins  beneath  it. 


128 


DISEASES   OF   WOMEN. 


tocele  caused  it  to  disappear  as  soon  as  the  blood  was  pressed  out  of 
the  enlarged  veins.  This  is  shown  in  Fig.  62.  An  argument  which 
has  been  made  against  this  by  one  of  my  friends,  to  whom  I  have 
explained  my  views  on  the  subject,  is  that  he  has  noticed  in  faecal 
accumulations  the  rectocele  protruding  through  the  vulva,  especially 
on  voluntary  eiiorts  being  made  to  evacuate  the  rectum.  This  is 
offset  by  the  fact  that  in  most  of  such  cases  I  have  found  that  when 
the  rectum  is  emptied  its  muscular  walls  contract  and  there  is  no 
diverticulum  left.  Of  course,  the  rectum  loses  its  support  when  the 
levator-ani  muscle  is  lacerated,  and  is  easily  overdistended,  and  the 
distention  must  be  toward  the  vagina  and  vulva,  but  is  temporary, 
not  permanent,  and  hence  not  a  rectocele.  I  may  say  further  in 
reference  to  this  form  of  injury  that  it  is  followed  by  pathological 
changes  which  give  rise  to  more  distressing  symptoms  than  any 
other.  It  is  in  this  form  of  injury  that  prolapsus  more  frequently 
occurs,  not  only  of  the  uterus  and  vaginal  walls,  but  also  of  the 
bladder ;  and  there  is  greater  liability  than  in  any  other  injury  to 
the  formation  of  varicose  veins  around  the  lower  portion  of  the 
vagina  and  rectum,  which  give  rise  to  no  small  degree  of  suii'ering. 
In  this  injury,  too,  subinvolution  of  the  vagina  and  uterus  most  fre- 
quently occurs.  More  than  that,  I  believe  that  there  is  in  addition 
to  the  subinvolution  of  the  vagina  a  certain  degree  of  areolar  hyper- 
plasia, which  accounts  for  the  extraordinary  thickening  of  the  vagi- 
nal walls  seen  in  this  class ;  still  more,  if  relief  is  not  obtained  there 
comes  a  time  when  atrophic  changes  of  the  vaginal  walls  take  place 

which  cause  fur- 
I  ther  changes  in 
the  venous  cir- 
culation, and  if 
the  injury  goes 
many  years  with- 
out repair,  atro- 
phy of  the  leva- 
tor -  ani  muscle 
occurs,  and  such 
changed  struc- 
tures become  ab- 

FiG.  6.3. — Beginning  atrophy  of  perineal  Iwdy  in  the  median  line.  Solutcly  incura- 
ble by  any  meth- 
od of  operating.  It  is  quite  a  number  of  years  (sixteen  or  eighteen) 
since  I  called  attention  to  the  atrophic  changes  in  the  muscles  which 
take  place  in  cases  of  long  standing,  and  though  a  certain  amount 


INJURIES  TO   THE   PELVIC  FLOOR. 


129 


■of  temporary  relief  is  obtained  by  operating,  prolapsus  of  all  the 
pelvic  organs  recurs. 

I  formerly  believed  that  in  connection  with  transverse  lacera- 
tions a  subcutaneous  laceration  in  the  median  line  (Fig.  63)  some- 
times occurred,  but  I  am  satisfied  now,  after  more  extended  obser- 
vation,   that    in 

n 


^^1' 


Fig.  64. — Atrophy  in  the  median  line,  with  sagging  of  the  pos- 
terior vaginal  wall  resembling  subcutaneous  transverse 
laceration. 


place  of  a  lacera- 
tion there  is  a 
thinning  out  and 
•absorption  of  the 
tissues  in  the  me- 
dian line  which 
produces  a  con- 
dition similar  to 
that  of  subcuta- 
neous laceration. 
This  absorption 
is  brought  about 
by  the  sagging  of 
the  pelvic  floor, 

which  makes  undue  traction  upon  the  transversus  perinsei  muscles 
and  fascia,  and  as  the  posterior  wall  becomes  prolapsed  additional 
pressure  is  made  at  that  point,  and  hence  the  absorption  or  atrophy 
which  takes  place  in  the  median  line.  This  change  of  structure 
resembles  in  every  particular  the  lesion  of  subcutaneous  laceration 
(Fig.  64),  but  it  is  only  found  in  cases  that  have  existed  for  a  long 
time,  in  which  there  is  marked  prolapsus  of  the  vaginal  walls  and, 
•of  course,  great  sagging  of  the  entire  pelvic  floor.  These  facts  in 
regard  to  pathology  have  a  very  important  bearing  upon  the  ques- 
tion of  treatment,  as  will  be  noted  further  on. 

Symptomatology. — The  symptoms  which  are  developed  by  inju- 
ries to  the  pelvic  floor  are  not  sufficiently  diagnostic,  or  else  they 
have  not  yet  been  sufiiciently  studied,  to  make  them  of  decided  value 
to  the  diagnostician.  Patients  have  a  feeling  of  want  of  support  of 
the  pelvic  organs,  or,  as  they  express  it,  a  dragging-down  feeling,  and 
some  derangement  of  the  functions  of  the  rectum  and  bladder,  but, 
as  these  symptoms  occur  in  all  the  forms  of  injury  named,  and  as 
they  also  in  like  manner  occur  in  displacement  of  the  pelvic  organs, 
but  little  reliance  can  be  placed  upon  them.  When  the  function  of 
the  levator-ani  muscle  is  lost  from  injury  or  atrophy,  there  is  usually 
much  difficulty  in  evacuating  the  rectum.  This  is,  of  course,  most 
marked  when  the  patient  is  constipated,  but  it  is  noticed  also  when 
10 


130  DISEASES  OF  WOMEN. 

the  bowels  are  free,  though  to  a  less  extent.  When  there  has  been 
a  laceration  in  the  median  line  the  scar  tissue  is  often  tender  to  the 
touch,  and  occasionally  causes  some  general  nervous  disturbance. 
The  sensitiveness  of  this  scar  tissue  is  sometimes  so  great  as  to  pro- 
duce reflex  muscular  contraction  when  touched  while  the  patient  is 
aniiesthetized.  The  admission  and  expulsion  of  air  from  the  vagina 
(flatus  vaginalis)  is  said  to  occur  frequently  in  these  injuries,  and  it 
is  no  doubt  one  of  the  most  reliable  symptoms  of  injuries  of  the 
pelvic  floor,  as  it  rarely  occurs  in  any  other  condition. 

In  cases  complicated  with  prolapsus  of  the  vaginal  walls,  blad- 
der, and  uterus  the  symptoms  belonging  to  these  affections  are  pres- 
ent. In  cases  of  laceration  in  the  median  line  involving  the  sphincter- 
ani  muscle  the  control  of  the  rectum  is  lost.  This  symptom  points 
to  the  nature  of  the  lesion  directly. 

Physical  Signs. — Inspection  reveals  the  structural  changes  that 
have  taken  place  in  the  lacerations  in  the  median  line,  so  that  the 
diagnosis  could  be  easily  made  by  direct  examination. 

Subcutaneous  lacerations  of  the  muscles  and  fascia  in  tlie  median 
line  are  detected  by  muscle  and  fascia.  These  escape  notice  at  the 
time  when  they  occur  unless  carefully  looked  for.  They  are  easily 
detected,  however,  by  grasping  the  pelvic  floor  in  the  median  line 
between  the  thumb  and  finger.  By  this  manipulation  it  will  be  found 
that  all  the  structures,  except  the  mucous  membrane  of  the  vagina 
and  integument,  have  been  divided  and  retracted,  and  there  is  noth- 
ing left  of  the  fascia  and  muscular  structure  in  the  median  line 
excepting  the  sphincter-ani  muscle. 

The  transverse  internal  laceration,  when  entirely  confined  to  the 
muscular  structures  of  the  vagina  and  levator-ani  muscle,  is  not  an 
easy  lesion  to  detect,  owdng  to  the  fact  that  a  similar  condition  is 
produced  by  sagging  of  the  pelvic  floor,  following  delivery  and 
temporary  paralysis. 

One  of  the  pathological  changes  which  take  place  in  transverse 
laceration  is  a  marked  sagging  of  the  pelvic  floor,  which  in  itself 
may  be  perfectly  normal  in  structure.  This  sagging  is  apparent 
upon  inspection,  and  the  diagnosis  of  this  laceration  is  made  from 
the  fact  that  under  stimulation  the  levat(»i--ani  muscle  fails  to  per- 
form its  function.  Tlie  action  of  this  nniscle  is  to  a  large  extent 
voluntary,  and  this  voluntary  power  is  lost  and  stimulation  fails  to 
call  it  into  action. 

Fig.  65  shows  the  downward  disjilacement  resulting  from  the 
injury  to  the  muscles.  This  displacement  can  be  demonstrated  upon 
the  subject  by  placing  one  finger  upon  the  pubes  and  the  other  on 


INJURIES  TO  THE   PELVIC  FLOOR. 


131 


the  tip  of  the  coccyx,  and  observing  the  extent  to  which  the  pelvic 
floor  projects  below  these  two  points.  Again,  by  placing  the  pa- 
tient upon  the  side  and  flexing  the  thighs  at  right  angles  with  the 
trunk,  the  downward  displace- 
ment becomes  apparent.  In  the 
most  pronounced  cases  the  parts 
project  downward  almost  on  a 
line  with  the  nates.  The  physical 
signs  of  this  condition  will  be  re- 
ferred to  again  in  connection  with 
atrophy  of  the  muscles,  and  the 
differential  points  will  be  noted. 

In  the  diagnosis  of  all  these 
injuries,  the  all-important  ques- 
tion is  to  determine  whether  the 
paralysis  is  due  to  overdistention 
of  the  muscles  and  is  temporary 
only,  or  due  to  atrophy,  and  hence 
permanent.  This  can  not  always 
be  settled  at  once  and  positively. 
If  the  tissues  of  the  pelvic  floor 
appear  to  the  touch  to  be  lacking 
muscular  fiber,  and  no  muscular 
contraction  can  be  induced  by 
stimulation,  it  is  presumptive  evi- 
dence of  muscular  atrophy ;  and 
yet  it  may  be  only  a  temporary 

loss  of  muscular  power.  It  is  necessary,  then,  to  support  the  pelvic 
floor  and  let  the  patient  rest  in  the  recumbent  position  to  remove 
all  downward  pressure  from  the  parts,  and,  by  the  use  of  astringents 
and  electricity,  endeavor  to  restore  the  muscular  function  sufliciently 
to  prove  that  there  is  still  muscular  tissue  present.  If  by  such 
means  the  muscular  function  is  even  partially  restored,  the  diagnosis 
is  completed,  and  the  indications  for  further  treatment  are  estab- 
lished. It  is  then,  and  only  then,  that  surgical  treatment  may  be 
employed  with  the  hope  of  obtaining  complete  recovery.  Should 
all  well-directed  efforts  fail  to  give  evidence  that  the  muscles  still 
retain  their  true  anatomical  characteristics,  it  is  useless  to  hope  for 
success  in  operating. 

Causation. — The  causes  of  these  injuries  of  the  pelvic  floor  are 
traumatic  (excepting  the  last  one  described),  that  is,  overdistention 
or  stretching  of  the  parts  during  parturition.     The  exceptions  to 


Fig.  65. — Sagging  of  the  pelvic  floor.  The 
sweep  from  A  to  B  denotes  the  sagging 
portion  of  the  pelvic  floor.  The  bulging 
posterior  vaginal  wall  (rectocele)  shows 
white  between  the  labia. 


132  DISEASES  OF   WOMEN. 

this  have  already  been  mentioned,  viz.,  long-continued  overdistention 
from  prolapsus  of  the  pelvic  organs,  extreme  constipation,  and  mal- 
nutrition in  old  age. 

There  are,  no  doubt,  certain  states  which  predispose  to  these  in- 
juries. Phlegmatic  women  who  have  failed  to  take  exercise  sufficient 
to  develop  these  muscles  are  liable  to  lacerations  during  parturition. 
In  such  cases  the  muscles  of  the  pelvic  floor  are  poor  in  quality,  and 
rupture  easily  under  extreme  pressure.  The  very  opposite  of  this 
apparently  predisposes  to  the  same  accidents.  In  vigorous  muscular 
women  the  pelvic  floor  is  often  unyielding  because  of  the  great 
strength  of  its  muscles.  They  resist  the  pressure  of  the  child  as  it  is 
forced  against  the  pelvic  floor  by  a  powerful  uterus,  and,  seemingly, 
rather  than  relax  and  stretch,  their  union  at  the  median  line  gives 
way;  it  is  in  such  cases  that  complete  laceration  in  the  flrst  degree 
is  most  likely  to  occur.  Again,  in  those  in  whom  the  pelvis  is  shal- 
low and  wide  in  the  straits,  the  child  passes  easily  through  the  pelvic 
canal,  when  rather  sudden,  unrestrained  pressure  comes  upon  the 
parts  and  they  are  very  liable  to  give  way.  In  others  still,  either  from 
habits  of  life  or  the  position  of  the  uterus  in  relation  to  the  pelvis, 
the  return  circulation  is  retarded,  the  vessels  become  overdistended, 
and  a  deranged  nutrition,  with  softening  of  the  tissues  of  the  pelvic 
floor,  renders  them  easily  torn. 

The  immediate  cause  of  lacerations,  whether  subcutaneous  or 
complete,  is  distention  during  delivery.  The  tissues  in  the  median 
line  give  way,  in  the  great  majority  of  cases,  because  the  greatest 
pressure  is  brought  to  bear  at  that  point.  That  the  laceration  ex- 
tends to,  but  not  through,  the  sphincter-ani  muscle,  as  a  rule,  is  no 
doubt  due  to  the  strength  of  this  muscle.  In  fact,  it  is  a  matter  of 
surprise  that  the  sphincter  is  ever  lacerated  when  its  position  is  con- 
sidered in  relation  to  the  force  brought  to  bear  upon  it.  The  only 
rational  explanation  of  the  laceration  which  I  have  been  able  to  ob- 
tain from  a  careful  clinical  study  of  the  matter  is  as  follows :  The 
transversus-perinnei,  levator-ani,  and  bull^o-cavernosus  muscles  are 
so  strongly  attached  to  the  s]ihincter-ani  muscles  that,  during  de- 
livery, when  the  head  distends  the  pelvic  floor  they  hold  the  sphinc- 
ter ani  upward  and  forward.  If  the  size  of  the  head  is  out  of  pro- 
portion to  the  distensibility  of  the  pelvic  floor,  one  of  two  injuries 
must  occur :  either  the  muscles  attached  to  the  sphincter  must  give 
way  and  permit  the  sphincter  to  recede  downward  and  escape 
injury,  or  else  the  sphincter  must  be  torn  through.  This  eftect 
of  the  other  muscles  upon  the  sphincter  ani  during  delivery  of  the 
child's  head  can  be  seen  by  the  way  in  which  the  sphincter  ani  is 


INJURIES   TO  THE   PELVIC  FLOOR.  133 

drawn  upward  until  the  anus  is  distended  an  inch  or  two.  While 
the  fetal  head  was  unusually  distending  the  pelvic  floor,  and  while 
the  hand  was  placed  upon  the  parts  to  "support  the  perinseum," 
I  have  felt,  or  fancied  that  I  could  feel,  the  muscles  attached  to  the 
sphincter  ani  give  way  and  permit  the  rectum  to  recede  and  escape 
injury. 

Regarding  the  causes  of  injuries  to  the  levator-ani  muscle,  one 
has  but  to  recall  the  phenomena  of  labor  as  related  to  it  to  under- 
stand how  it  may  be  freely  lacerated  in  ordinary  labor.  It  cer- 
tainly is  as  fully  exposed  to  injury  as  the  other  muscles  which  we 
know  are  frequently  lacerated  subcutaneously.  In  delivery  with  for- 
ceps, the  levator-ani  muscle  is  frequently  injured,  I  believe.  While 
the  child's  head  is  in  the  grasp  of  the  forceps  and  during  traction, 
I  have  noticed,  by  passing  the  finger  into  the  rectum,  that  the  levator 
ani  was  drawn  so  tightly  over  the  edges  of  the  blades  of  the  forceps 
that  it  appeared  as  if  it  must  be  torn,  and  I  feel  sure  that  it  often  is. 
I  am  the  more  fully  convinced  of  the  truth  of  this  by  having  care- 
fully watched  patients  that  I  had  delivered  with  forceps,  and  have 
found  in  some  of  them  evidence  of  injury  of  the  levator  ani  above 
its  lower  attachment.  That  evidence  was  obtained  by  finding,  on 
subsequent  vaginal  examination,  that  the  resistance  of  the  levator 
muscle  usually  found  was  wanting,  and  also  that  there  was  pro- 
lapsus of  the  pelvic  floor,  and  loss  of  contractility  upon  irritating 
the  parts. 

Ti'eatinent. — The  object  in  treating  these  injuries  should  be  to 
restore  the  lacerated  muscles  by  securing  union  of  their  severed 
fibers.  In  the  ordinary  or  most  commonly  recognized  injury,  lacera- 
tion in  the  median  line  down  to,  but  not  through,  the  sphincter,  the 
immediate  treatment  usually  employed  is  to  close  the  wound  with 
sutures  at  once,  or  to  cleanse  the  wound  from  blood  clots  and  coapt 
the  parts,  carefully  bind  the  patient's  limbs  together,  and  trust  that 
union  may  follow.  The  treatment  by  the  immediate  use  of  the 
suture  will  be  made  plain  by  the  following : 

Primary  Operation. — The  wound,  if  seen  when  it  occurs,  is  tri- 
angular, the  base  running  parallel  to  the  rectum  and  the  apex  being 
at  the  posterior  part  of  the  vulva.  The  sides  of  the  wound  come  to- 
gether quite  easily,  and  only  require  well-adjusted  sutures  to  keep 
them  in  position.  Much  care  is  necessary  in  using  the  sutures.  If 
they  are  imperfectly  introduced  they  do  harm  by  preventing  the  union 
which  often  takes  place  without  surgical  aid.  If  one  is  not  accus- 
tomed to  this  simple  operation  of  closing  the  wound  with  sutures,  it 
w^ould  be  infinitely  better  for  the  patient  to  trust  to  nature  than  to 


134 


DISEASES  OF   WOMEN. 


IIUICOLIS 


shin 


QQ.      The    center    lines   ^^^-  66.-Diagram  of  the  sweep  of 

the  suture. 


have  tlie  surgeon  employ  sutures  in  a  bungling  way.  The  sutures 
should  be  introduced  as  follows :  The  needle,  held  in  the  groove  at 
right  angles  to  the  forceps,  should  be  entered  in  the  skin  exactly  at 
the  edge  of  the  wound,  and  as  far  down  as  the  deepest  part ;  it  is  then 
carried  into  the  tissues  and  made  to  describe  the  arc  of  a  circle  and 
emerge  at  the  margin  of  the  mucous 
membrane  of  the  vagina.  The  needle 
is  again  introduced  on  the  opposite  side 
and  cari'ied  through  as  before,  and 
brought  out  at  the  point  in  the  skin 
opposite  where  it  was  first  introduced. 
If  this  is  properly  done,  the  position  of 
the  suture  in  the  tissue  will  be  as  repre- 
sented   in    Fi^ 

repi'esent  the  sides  of  the  wound,  and  the 
dotted  line  shows  the  suture,  which  describes  a  circle,  the  point  at 
which  the  suture  is  tied  and  the  opposite  point  of  its  circumference 
being  at  the  upper  and  lower  angles  of  the  wound.  There  are  three 
advantages  in  using  the  suture  in  this  way :  First,  the  ends  of  the 
suture  coming  out  at  the  edges  of  the  wound  hold  the  parts  exactly 
together  without  the  aid  of  superficial  sutui-es ;  second,  the  curve 
which  the  suture  takes  deep  under  the  tissues 
brings  the  central  portions  of  the  wound 
together,  whereas,  if  the  suture  is  passed 
straight  through  the  tissues,  the  edges  of  the 
wound  would  curve  inward,  while  the  cen- 
FiGs.  67,  68.— Sutiires  prop-  tral  parts  would  not  meet.  Fig.  67  shows 
erly  and  improperly  intro-  tj^e  parts  adjusted  by  a  proper  suture,  while 
Fig.  68  shows  the  effect  of  the  imperfect 
one.  Again,  the  suture  running  deep  into  the  tissues  gives  addi- 
tional surety  of  catching  the  ends  of  the  muscles  so  as  to  reunite 
them,  which  is  the  chief  object  of  the  operation.  In  the  primary 
operation — i.  e.,  the  introduction  of  sutures  immediately  after  the 
injury  occurs — Peaslee's  needle  is  easier  to  use  than  the  ordinary 


71 


Fig.  69. — Poaslee's  needle. 


perineal  needle.  Fig.  69  shows  the  instrument.  This  needle,  with  a 
handle,  and  an  eye  near  the  point,  is  armed  with  a  thread  and  passed 
through  the  tissues  as  already  described,  and  the  end  of  the  suture  is 
passed  under  the  thread  in  the  needle  ;  this  is  then  withdrawn  and 


INJURIES  TO   TPIE   PELVIC   FLOOR.  135 

TDrings  one  end  of  the  suture  into  the  tissues.  The  operation  is  re- 
peated on  the  other  side,  wliich  completes  the  introduction  of  the 
suture.  The  only  advantage  of  this  needle  is  that  it  is  easier  to  man- 
age than  the  ordinary  one.  It  can  only  be  used,  however,  in  the 
primary  operation.  The  silk  suture  properly  prepared  is  by  far 
the  best  for  the  immediate  operation.  Silver  wire,  which  at  one 
time  was  the  only  suture  which  could  be  relied  upon,  has  been 
■superseded  by  others  that  are  vastly  superior  for  tliis  purpose.  It 
is  impossible  to  keep  the  parts  clean  after  confinement  without 
causing  pain  while  the  ends  of  silver-wire  sutures  are  projecting 
from  the  parts.  Catgut  sutures  are  employed  by  some,  but  they  are 
most  unsatisfactoi'y.  They  decompose,  and  by  causing  suppuration 
prevent  healing. 

Apfelstedt  recommends  the  method  proposed  by  Yeit  of  confin- 
ing the  suture  to  the  perinyeum  in  the  closure  of  recent  tears,  on  the 
ground  (1)  that  needle  holes  in  the  vagina  or  rectum  favor  infection 
of  the  wound  ;  (2)  that  too  many  stitches  destroy  too  much  tissue  ; 
and  (3)  that  when  they  are  knotted  a  cavity  is  likely  to  be  left  in  the 
wound.  He  uses  two  needles  to  each  thread  of  silkworm  gut  or 
silk  ;  these  are  inserted  where  the  wounded  surfaces  meet,  so  as  to 
emerge  near  the  perineal  wound.  The  first  needle  passes  two  milli- 
metres below  the  junction  of  the  two  wounded  edges  of  mucosa,  and 
the  lowest  in  the  same  way,  two  millimetres  above  the  point  where 
the  edges  of  the  wound  in  the  rectal  mucosa  meet,  the  lines  of  the 
stitches  spreading  toward  the  perineum  like  a  fan.  Six  or  eight 
sutures  are  enough.  The  middle  ones  are  drawn  quite  tight,  the 
others  but  moderately  so  before  being  knotted.  This  method  has 
been  used  by  Apfelstedt  since  1892.  All  the  vagino-perineal  lacera- 
tions have  healed,  and  three  out  of  four  total  lacerations. 

This  constitutes  the  whole  primary  treatment  of  injuries  of  the 
pelvic  floor,  as  given  in  our  text-books — a  kind  of  management  gen- 
erally sufficient  in  central  lacerations,  but  that  can  have  little  influ- 
ence in  restoring  the  other  forms  of  injury.  To  secure  the  reunion 
of  the  muscles  that  have  been  lacerated  subcutaneously,  especially 
the  levator  ani,  the  parts  should  be  well  supported  and  kept  at  rest. 
If  the  pelvic  floor  is  permitted  to  remain  in  its  relaxed  and  displaced 
position  there  is  but  little  chance  of  the  lacerated  muscles  uniting, 
nor,  in  case  they  are  simply  overtaxed  by  distention,  will  they  regain 
their  tonicity  promptly  if  left  unaided  by  support.  Especially  is 
restoration  likely  to  be  prevented  if  the  patient  is  permitted  to  as- 
sume the  erect  position  too  soon,  and  if,  to  increase  the  injurious 
effects  of  this  unwise  liberty,  the  uterus  is  crowded  down  into  the 


136  DISEASES   OF   AVOMEN. 

pelvis  by  a  compress  and  tight  bandage  applied  around  the  body. 
In  all  eases  of  injury  in  which  concealed  laceration  of  the  muscles  ia 
suspected,  the  pelvic  floor  should  be  well  supported  with  a  compress 
and  bandage  fastened  to  the  abdominal  binder.  By  these  means  the 
severed  ends  of  the  muscular  libers  are  brought  nearer  together,  so 
that  they  have  a  better  chance  to  unite.  An  objection  would  natu- 
rally be  raised  to  this  treatment  on  the  ground  that  it  would  obstruct 
the  free  flow  of  the  lochia.  This  can  be  overcome  by  making  the 
compress  of  absorbent  cotton,  antiseptic  gauze,  or  marine  lint,  and 
draining  the  vagina  with  a  drainage-tube  or  a  strip  of  gauze  or  lint. 
I  believe  that  in  this  way  the  vagina  can  be  drained  and  kept  as 
clean  as  it  can  be  by  occasional  douching.  In  fact,  I  am  inclined  to 
think  that  the  very  frequent  use  of  vaginal  injections  so  generally 
employed  in  this  age  of  antiseptic  obstetrical  practice  often  tends  to 
retard  the  restoration  of  injuries  of  the  pelvic  floor.  It  is  well,  also, 
to  let  the  patient  rest  upon  either  side  after  the  first  twelve  or 
twenty-four  hours.  This  position  takes  ofE  all  pressure  from  above, 
and  favors  the  upward  inclination  of  the  pelvic  floor.  Great  care 
should  be  taken  to  avoid  distention  of  the  bladder  and  rectum.  Con- 
stipation after  confinement  is  almost  sure  to  prevent  or,  at  least, 
retard  recovery.  By  attending  to  these  siiiiple  means  much  can  be 
done  toward  preventing  that  incurable  condition,  permanent  paraly- 
sis from  atrophy. 

After  convalescence  from  confinement,  in  case  it  is  found  that, 
although  there  is  no  complete  loss  of  muscular  action  in  any  part  of 
the  pelvic  floor,  there  is  a  muscular  weakness  shown  by  the  impaired 
power  of  resistance  to  pressure,  the  supporting  treatment,  with  judi- 
cious rest  and  exercise  well  regulated,  should  be  kept  up  until 
strength  is  restored. 

The  restoration  of  the  function  of  the  muscles,  as  already  stated 
in  speaking  of  general  treatment,  is  the  great  object  of  all  surgical 
operations  for  the  relief  of  these  injuries  of  the  pelvic  floor.  It 
matters  not  how  mucli  tissue  may  be  gathered  together  and  united 
in  the  region  of  the  perineal  body,  it  will  have  no  functional  action 
if  destitute  of  muscular  tissue.  The  success  of  all  surgical  proced- 
ures depends  upon  the  restoration  of  the  muscles,  elastic  tissue,  and 
fascia,  and  not  the  mere  uniting  of  the  tegumentary  and  areolar 
tissue. 

In  this  plastic  operation,  known  as  perineorrhaphy,  or  restoration 
of  the  perinaeuin,  much  surgical  skill  is  necessary  in  order  to  succeed. 
This  is  true  of  all  operative  surgery,  and  yet  special  care  is  necessary 
in  this  operation,  because  union  l)y  first  intention  must  be  secured 


INJURIES   TO   THE   PELVIC   FLOOR.  •    137 

or  else  the  operation  will  fail.  In  many  operations  in  surgery,  if 
the  wound  does  not  heal  by  tirst  intention,  union  may  be  secured  by 
granulation  and  a  perfect  result  obtained ;  but  in  the  operation 
under  consideration,  if  the  whole  or  any  part  fails  to  unite  promptly, 
partial  or  complete  failure  is  the  result.  This  calls  for  the  employ- 
ment of  all  known  surgical  means  most  favorable  to  prompt  healing. 
On  this  account,  then,  some  general  considerations  regarding  plastic 
operations  in  gynecology  will  be  in  place  before  describing  the 
methods  of  operating.  What  will  follow  on  this  subject  will  apply 
equally  to  all  operations  about  the  pelvic  floor  and  pelvic  organs, 
especially  lacerations  of  the  cervix  uteri. 

The  following  may  be  given  as  the  conditions  necessary  for  the 
healing  of  the  wounds  in  question  : 

1.  A  condition  of  the  wound  and  of  the  general  system  favorable 
to  the  repair  of  injuries. 

2.  Perfect  coaptation  and  retention  of  the  parts  to  be  united,  and 
protection  of  the  parts  from  extrinsic  and  otEending  agents  during 
and  after  coa^Dtation. 

If  these  conditions  are  all  secured,  success  must  of  necessity  fol- 
low. The  management  of  wounds  is  not  a  matter  of  blind  chance. 
The  process  of  repair  in  living  tissues  is  governed  by  definite  laws 
which  are  always  the  same  under  identical  circumstances.  To  ob- 
tain the  conditions  necessar}-  to  the  fulfillment  of  these  laws  is  often 
difficult  and  sometimes  impossible;  still,  the  nearer  we  come  to  all 
the  requirements  the  more  surely  will  the  desired  ends  be  accom- 
plished. 

The  first  of  these  conditions,  viz.,  good  general  health,  may  be 
found  wanting  in  many  ways  and  degrees  which  are  too  familiar  to 
require  notice,  but  there  are  some  of  these  which  may  be  mentioned 
because  they  are  very  often  overlooked — preoccupation  of  the  sys- 
tem by  some  highly  taxing  function,  like  lactation,  for  example,  and 
certain  deranged  states  of  the  nervous  system.  These  certainly  have 
an  important  bearing  upon  the  healing  of  wounds,  although  little  if 
anything  is  said  in  our  works  on  surgery  regarding  them.  In  fact, 
there  is  good  reason  for  believing  that  enfeebled  states  of  the  nerv- 
ous system  have  much  to  do  with  retarding  the  healing  of  wounds, 
even  when  the  general  nutrition  appears  to  be  normal.  We  fre- 
quently hear  surgeons  say  that  patients  recover  from  injuries  much 
more  promptly  when  they  have  courage  and  hope  without  fear ;  but 
exhausted  and  irritable  states  of  the  nervous  system  retard  the  pro- 
cess of  repair,  although  the  patient  may  be  indifferent  or  perfectl,y 
satisfied  in  regard  to  recovery. 


138  DISEASES   OF  WOMEN. 

Regarding  the  unfavorable  conditions  of  the  tissues  generally 
met  with,  the  following  are  the  most  important : 

Contusions. — Contusions  accomj^anying  wounds  caused  by  par- 
turition. Lacerated  wounds  of  the  pelvic  organs  often  heal  promptly 
if  well  coaptated  immediately  after  they  occur,  but  no  such  union 
should  be  expected  in  case  the  tissues  are  greatly  contused.  While 
this  is  true  of  the  immediate  treatment  of  wounds  sustained  during 
labor,  it  is  pretty  definitely  settled  that  operation  wounds  made  dur- 
ing the  process  of  involution — that  is,  within  four  or  six  weeks  after 
confinement — often  fail  to  unite.  From  this  we  learn  that  while 
tissues  are  undergoing  involution  they  are  not  in  the  best  condition 
to  heal ;  and  also  that,  when  involution  is  delayed  beyond  the  usual 
time,  treatment  should  be  employed  to  complete  the  process  before 
undertaking  plastic  operations. 

Scrupulous  care  is  also  required  in  preparing  the  tissues  by  mak- 
ing clean,  accurate  incisions  which  will  give  smooth  surfaces  to  the 
parts  to  be  united.  Old  scar  tissue  should  also  be  removed  from  all 
wounds  where  union  by  first  intention  is  desired.  These  are  rules 
in  surgery  which  are  well  known,  but  they  are  sometimes  overlooked 
in  practice. 

Ihemorrhage. — Hsemorrhage  in  these  operations  is  often  a  source 
of  difficulty  and  delay  to  the  operator,  but,  worse  than  that,  it  is 
sometimes  the  cause  of  failure.  In  the  vast  majority  of  surgical 
operations  all  that  is  required  of  the  surgeon  is  to  arrest  the  haemor- 
rhage, by  any  of  the  ordinary  means,  in  order  to  secure  a  good  re- 
sult ;  but  in  the  operations  in  question,  if  some  kinds  of  styptics 
are  used,  they  prevent  union.  Cases  differ  so  very  much  in  regard 
to  haemorrhage  that  I  have  given  much  thought  to  the  predisposing 
causes  of  this  bleeding  tendency,  so  marked  in  some  patients.  The 
haemorrhagic  diathesis  in  its  most  typical  form  is  generally  found 
in  men,  but  a  less  marked  haemorrhagic  tendency  is  common  to 
many  women,  and  these  are  very  unpleasant  subjects  to  operate 
upon.  During  the  past  few  years  it  has  been  my  misfortune  to 
meet  with  quite  a  number  of  cases  in  which  the  bleeding  tendency 
was  noticeable.  The  cause  of  this  in  most  of  them,  I  think,  was  im- 
paired general  health,  due  to  exhausting  conditions  of  life  rather 
than  to  any  congenital  imperfection  of  the  blood  itself.  Another 
very  important  element  I  have  found  to  be  mechanical  inteiTuption 
of  the  circulation,  the  pelvic  organs  becoming  congested  from  re- 
tardation of  the  portal  circulation,  induced  by  hepatic  disorders, 
sedentary  habits,  tight  lacing,  and  so  forth.  The  products  of  former 
pelvic  inflammations,  such  as  pelvic  cellulitis,  also  tend  to  maintain 


IIJJURIES  TO   THE   PELVIC   FLOOR.  139 

a  liypersemic  state  of  the  pelvic  organs ;  this  we  often  find  long  after 
all  evidence  of  active  iiiHannnation  has  subsided.  The  condition  at 
the  time  also  is  often  favorable  for  bleeding ;  the  well-defined  vas- 
cularity which  exists  in  conditions  such  as  imperfect  involution  in- 
sures hcTemorrhage  in  all  operations  undertaken  during  such  unfavor- 
able states.  The  possible  haemorrhage  from  such  causes  can  be 
avoided  by  the  proper  selection  and  preparation  of  cases  before  oper- 
ating. 

The  rule  which  should  be  followed  in  this  matter  is  to  secure  the 
best  possible  state  of  the  general  health  of  the  patient,  and  to  reduce 
all  hyperfemic  states  of  the  pelvic  organs  as  far  as  possible.  This  is 
generally  possible  to  a  great  extent,  because  the  object  of  plastic 
operations  is  to  restore  the  organs  to  their  original  form  and  struct- 
ure, differing  in  this  regard  from  many  other  operations  in  surgery 
which  have  for  their  object  the  removal  of  diseased  parts. 

In  carrying  out  this  plan  of  treatment,  however,  there  is  one 
difiiculty  encountered  in  practice ;  when  patients  are  ill  and  suffer- 
ing they  will  gladly  accept  any  operation  which  promises  them  relief, 
but,  when  they  are  free  from  pain  and  have  gained  in  health,  they 
hesitate  about  undergoing  any  surgical  treatment  which  is  designed 
to  keep  them  from  suffering  in  the  future.  This,  however,  does  not 
prevent  the  surgeon  from  advising  that  which  is  best.  There  are 
patients — fortunately  very  few — who  have  the  hseraorrhagic  diathesis 
sufficiently  marked  to  debar  them  from  operations,  and  it  is  doubtful 
if  any  preparatory  treatment  will  change  this  constitutional  pecul- 
iarity. Such  subjects  should  be  let  alone ;  to  operate  in  these  cases 
is  dangerous,  and  almost  always  ends  in  failure.  I  have  had  three 
such  cases  in  the  past  five  years ;  two  of  them  were  operated  ujDon 
before  discovering  their  peculiarity,  the  result  being  depletion  of 
the  patients  without  any  benefit  from  the  operation,  and  the  devel- 
opment of  extreme  caution  on  the  part  of  the  operator  in  selecting 
cases  in  future.  The  third  case  was  diagnosticated  earlier,  and  I 
declined  to  operate. 

The  management  of  bleeding  vessels  in  these  operation  wounds 
is  of  great  importance.  All  haemorrhage  should  be  arrested  before 
bringing  the  parts  together,  because  a  slight  oozing,  which  would  do 
no  harm  in  a  wound  to  be  treated  by  open  dressing,  may  jDrevent 
union  in  wounds  in  which  drainage  should  not  be  emplo^'ed,  or,  at 
least,  should  not  necessarily  be  required.  This  often  requires  an 
amount  of  time  which  the  surgeon  reluctantly  bestows,  but  success 
in  treating  this  class  of  wounds  depends  largely  upon  attention  to 
this  matter.    Still  more,  the  means  used  to  arrest  haemorrhage  should 


140  DISEASES  OF  WOMEX. 

be  such  as  will  not  interfere  witli  tlie  process  of  healing.  Hitherto 
the  means  employed  have  been  ligation  or  torsion  of  the  large  vessels, 
and  for  minor  bleeding  the  use  of  ice  or  cold  water.  Moi'e  recent 
experience  has  pointed  out  objections  to  these  means.  Chilling  the 
tissues  by  cold  is  injurious,  it  is  said,  and  no  doubt  the  statement  is 
true.  It  has,  fortunately,  been  found  that  hot  water  is  more  efficient 
in  controlling  haemorrhage,  and  its  eftects  upon  the  tissues  are  not 
unfavorable — hence  its  use  as  a  styptic  in  these  operation  wounds  is 
strongly  commended.  Torsion  is  objectionable,  because  it  is  less 
certain  to  control  bleeding  than  the  ligature,  and  quite  as  liable  to 
give  rise  to  suppuration.  In  view  of  this  fact,  it  may  be  said  without 
doubt  that  the  antiseptic  ligature  is  the  best  means  of  controlling  the 
vessels  in  these  wounds.  Regarding  the  material  to  be  used  as  a 
ligature,  it  may  be  said  that  that  which  can  be  inclosed  in  the  wound 
without  giving  subsequent  trouble  is  the  thing  required.  The  prop- 
erly-prepared catgut  ligature  fulfills  the  indications.  Some  recent 
expei'ience  indicates  that  the  Japanese  ligature,  made  of  whale-sinew, 
is  the  best,  owing  to  its  being  absorbed  with  great  facility.  Occa- 
sionally, in  deep  lacerations,  a  small  artery  on  each  side  may  require 
to  be  ligated ;  the  chief  arterial  bleeding,  however,  comes  from  the 
upper  portion,  the  small  vessels  coming  apparently  from  above  down- 
ward in  the  areolar  tissue,  between  the  rectum  and  vagina.  These 
sometimes  bleed  quite  freely,  and  they  are  not  controlled  by  tighten- 
ing the  sutures,  which  arrest  the  heemorrhage  at  points  lower  down. 
Such  vessels  I  control  by  passing  a  needle  through  the  vaginal  mu- 
cous membrane  above  the  denuded  surfaces,  and  thus  carry  a  ligature 
under  the  bleeding  vessels,  tying  it  over  the  free  surface,  checking 
the  bleeding  on  the  principle  of  acupressure.  The  sutures  can  be 
left  in  position  until  the  perimBum  has  completely  healed  ;  they  can 
then  be  removed  wnth  the  aid  of  the  speculum.  Occasionally  it  be- 
comes necessary  to  ligate  some  of  these  vessels  which  bleed  persist- 
ently and  can  not  be  controlled  in  the  way  I  have  previously  de- 
scribed ;  it  is  then  well  to  ligate  them  with  a  tine  catgut  ligature,  the 
ends  being  cut  off  short  and  inclosed  in  the  wound. 

In  spite,  however,  of  all  precautions,  secondary  hsemorrhage  will 
occasionally  occur  after  this  operation.  I  have  met  with  four  such 
cases  in  my  practice ;  in  one  of  them  it  occurred  on  the  seventh 
day  after  the  operation.  In  all  of  them  the  bleeding  took  place  fi-om 
the  upper  or  vaginal  portion  of  the  wound,  the  blood  flowing  into 
and  widely  distending  the  vagina  before  appearing  externally. 

In  my  first  case  I  was  obliged  to  remove  the  sutures,  empty  the 
vagina  of  blood-clots,  and  ligate  the  bleeding  vessels.     This  resulted 


INJURIES  TO   THE   PELVIC   FLOOR.  141 

in  spoiling  mj  operation,  for,  although  I  reintroduced  the  sutures, 
union  did  not  take  place.  This  haemorrhage  occurred  on  the  sec- 
ond day. 

In  my  three  subsequent  cases  I  secured  much  better  results.  In- 
troducing a  Sims's  speculum  on  the  anterior  side  of  the  vagina,  I 
removed  the  clots  and  blood  by  sponging,  and  then,  throwing  light 
into  the  vagina  by  means  of  a  concave  reflector,  1  was  al>le  to  see 
that  the  blood  welled  up  from  the  upper  portion  of  the  wound.  In 
])lace  of  pulling  the  edges  of  the  wound  apart  and  searching  for  the 
bleeding  vessels,  I  passed  a  cmwed  needle  and  ligature  down  and 
around  the  place  where  the  bleeding  came  from,  and  was  able,  by 
tightening  my  ligature  moderately,  to  control  the  bleeding  entirely. 
These  eases  subsequently  did  well,  and  the  result  of  the  operation 
was  good. 

Sutures. — The  coaj^tation  of  the  tissues  by  means  of  sutures  re- 
quires more  than  a  passing  notice. 

The  success  which  J.  Marion-Sims  obtained  with  the  silver-wire 
suture  led  at  once  to  its  general  use  in  gynecological  operations. 
There  is,  however,  good  reason  for  believing  that  the  results  obtained 
by  that  great  surgeon  depended  as  much  upon,  his  skiU  in  using  sut- 
ures as  upon  the  material  which  he  used. 

To-day  we  know  that  it  matters  little  whether  silver- wire  or  pre- 
pared silk  sutures  are  used,  provided  they  are  properly  introduced. 
The  silk  selected  should  be  braided,  and  not  the  twisted  variety,  for 
the  reason  that  the  braided  silk  retains  wax  much  better,  and  does 
not  unravel  on  being  handled.  The  wax  in  the  twisted  silk  breaks 
and  separates  from  the  silk,  and  the  silk  thereby  becomes  porous 
and  will  absorb  blood-serum  which  readily  decomposes.  The  reason 
why  surgeons  formerly  failed  in  the  operation  for  vesico-vaginal 
iistula,  when  they  used  silk,  was  because  the  organic  matter,  ab- 
sorbed by  the  unprepared  silk,  decomposed  and  caused  septic  inflam- 
mation. The  braided  silk,  properly  saturated  with  wax,  overcomes 
this  completely.  The  parts  to  be  united  should  be  brought  together 
and  held  there  without  any  straining  upon  the  sutures.  It  is  equally 
important  to  introduce  the  sutures  so  that  they  will  prevent  the  in- 
curving of  the  undenuded  edges  of  the  parts  to  be  united,  and, 
finally,  a  sufiicient  number  of  sutures  should  be  employed  to  secure 
uniform  retaining  pressure  at  all  parts  of  the  wound. 

These  are  facts  which  every  one  is  supposed  to  know  before  en- 
gaging in  surgery,  but  in  practice  a  large  number  of  failures  are  seen 
because  of  neglect  in  regard  to  them. 

The  management  of  these  wounds  during  the  healing  process 


142  DISEASES   OF  WOMEN. 

differs  somewhat  from  the  modern  treatment  of  wounds  in  gen- 
eral. 

Dressings. — The  antiseptic  dressings  which  surgeons  use  in  some 
form  or  other  are  difhcult  of  application  in  the  operations  for  restor- 
ing tlie  cervix  uteri  and  jDerinseum.  So  fully  is  this  the  case  that 
some  of  our  highest  authorities  on  gynecology  make  no  pretensions 
to  using  antiseptic  treatment  in  such  wounds,  unless  frequent  bath- 
ing of  the  parts  with  water  and  carbohc  acid  may  be  called  such. 
No  doubt  some  of  our  best  operators  get  good  results  with  this  kind 
of  after-treatment,  but  it  is  more  than  probable  that  still  better  re- 
sults can  be  obtained  by  treatment  more  in  accordance  with  the  rules 
of  antiseptic  surgery.  Viewed  in  the  light  of  modern  investigation, 
it  appears  that  the  frequent  douching  of  wounds  with  carbolized 
water  is  a  practice  at  least  ten  years  behind  the  surgery  of  to-day. 

In  treating  wounds  of  the  perinaeum  there  are  many  perplexing 
difficulties  in  the  way  of  obtaining  a  proper  antiseptic  dressing. 
Here,  also,  the  vaginal  douche  has  been  freely  used,  for  the  purpose, 
it  is  said,  of  removing  vaginal  secretions  which  might  irritate  the 
wound  and  prevent  its  healing.  Such  treatment  is  generally  un- 
necessary, if  not  injurious.  In  all  operations  for  repairing  old  injuries 
of  the  periniieum  it  is  better  to  first  cure  all  uterine  and  vaginal  dis- 
eases which  give  rise  to  abnormal  discharges.  That  is  the  only  sure 
way  of  protecting  the  operation  wound  from  that  source  of  disturb- 
ance. This,  of  course,  can  not  be  accomplished  in  the  treatment  of 
lacerations  immediately  after  confinement.  Then  it  becomes  a  very 
important  question  how  to  protect  the  perineal  wound  from  the 
lochia.  Various  means  have  been  suggested  for  this  purpose,  such 
as  coating  the  vaginal  surface  of  the  w^ound  with  collodion,  placing 
carbolized  lint  or  borated  cotton  upon  the  inner  portion  of  the  wound, 
and,  the  most  common  of  all,  the  frequent  use  of  vaginal  injections. 
It  is  hardly  possible  to  say,  at  the  present  time,  which  is  best.  The 
collodion  has  not  been  tried  often  enough  to  speak  positively  regard- 
ing it.  In  using  the  lint  or  cotton  there  is  danger  of  separating  the 
edges  of  the  wound,  the  very  thing  of  all  others  to  be  avoided. 
Perhaps  the  best  treatment,  after  carefully  cleansing  the  parts  and 
bringing  them  accurately  together,  is  to  let  the  wound  alone  for  about 
two  days,  trusting  that  during  this  time  it  may  become  sufficiently 
protected,  by  a  coating  of  fresh  lymph,  to  resist  the  subsequent  dis- 
charges. After  the  lochia  begin  to  decom))ose,  the  frequent  use  of 
the  vaginal  douche  is  advisable,  and  should  be  continued  until  the 
union  is  completed. 

In  the  secondary  operation  for  restoring  the  perinseum,  the  vag- 


INJURIES  TO   THE   PELVIC  FLOOR.  143 

inal  portion  of  the  wound  may  generally  be  left  alone.  It  is  pro- 
tected from  the  air  by  the  anterior  vaginal  wall,  which  makes  a  suit- 
able dressing  provided  the  uterus  and  vagina  are  in  a  normal  condition, 
as  they  should  be,  before  the  operation  is  done.  If  suppuration  takes 
place  and  pus  is  discharged  into  the  vagina,  it  should  be  disposed  of 
by  injections.  The  outer  portion  of  the  w^ound  may  also  be  left 
without  dressing,  but  it  is  better  to  apply  lint  or  cotton  upon  each 
side  of  the  sutures ;  if  silver  wire  is  used,  or  if  silk  is  employed,  the 
lint  can  be  placed  over  the  wound  and  retained  in  place  by  keeping 
the  limbs  together.  The  advantage  of  this  kind  of  dressing  is  that 
it  absorbs  any  discharge  that  there  may  be. 

Perhaps  the  most  important  point  of  all  in  the  management  of 
such  cases  is  to  keep  from  dropping  urine  upon  the  wound.  The  most 
scrupulous  care  should  be  taken  to  close  the  end  of  the  catheter  in 
withdrawing  it.  If  this  is  neglected,  a  few  drops  of  urine  will  escape 
from  the  eye  of  the  instrument,  and,  falling  upon  the  wound,  will 
cause  trouble.  The  nurse  should  be  carefully  instructed  to  use  the 
catheter  in  this  way,  and,  to  make  doubly  sure  of  cleanliness,  a  httle 
absorbent  cotton  should  be  placed  between  the  meatus  urinarias  and 
the  wound  every  time  the  instrument  is  used. 

Notwithstanding  all  this  care,  suppuration  wdll  sometimes  occur^ 
and  then  the  question  arises  how  to  manage  this  complication.  If 
the  suppuration  is  limited  to  the  track  of  one  suture,  that  one  may 
be  removed  and  the  remaining  ones  trusted  to  keep  the  parts  to- 
gether. It  sometimes  happens  that  a  cellulitis  which  begins  in  the 
region  of  the  sutures  extends  outward  and  ends  in  suppuration. 
This  should  be  treated  by  a  free  incision  and  drainage,  which  may 
save  the  operation.  On  the  other  hand,  if  suppuration  takes  place 
between  the  surfaces  to  be  united,  there  is  very  little  hope  of  obtain- 
ing union  at  all  by  any  kind  of  treatment.  A  partial  or  even  com- 
plete success  may  be  obtained  in  such  cases  if  the  suppurative  process 
is  detected  early,  and  drainage  from  the  lower  edge  of  the  wound  is 
established.  This  can  be  effected  by  loosening  one  or  more  of  the 
sutures,  and  then  introducing  carbolized  silk  thread  to  secure  the 
free  escape  of  the  inflammatory  products. 

DESCRIPTION    OF    THE    OPERATION    FOR    RUPTURE    IN    THE 

MEDIAN    LINE. 

The  first  part  of  the  operation  consists  in  denuding  the  sur- 
faces to  be  united.  The  extent  to  which  this  should  be  carried 
depends  upon  the  character  of  the  injury.     If  there  is  no  prolap- 


144 


DISEASES  OF  WOMEN. 


sus  of  the  pelvic  floor  of  the  posterior  vaginal  wall  (see  Fig.  65),  it 
will  suffice  to  denude  the  surfaces  as  far  as  the  original  laceration 
extended  and  no  farther.  This  can  be  done  by  tracing  the  out- 
line of  the  scar  tissue  formed  by  the  healing  after  the  laceration. 
This  scar  tissue  contracts  and  brings  the  normal  tissues  toward 
each  other  so  that  the  portion  to  be  exsected,  as  indicated  by  the 
rule  given  here,  appears  to  be  very  small  and  insufficient ;  but,  when 
the  scar  tissue  is  removed,  the  skin  and  mucous  membrane  retract 
and  make  the  denuded  surface  large  enough — much  larger,  in  fact, 
than  the  piece  of  tissue  taken  away.  If  more  tissue  is  removed  in 
such  cases  and  good  union  is  obtained,  the  introitus  vaginae  is  made 
too  small. 

When  the  sides  of  the  laceration  are  drawn  outward  and  the  pel- 
vic floor  is  prolapsed,  and  the  distance  from  the  meatus  urinarius  to 
the  anterior  portion  of  the  sphincter  ani  is  increased  to  an  abnormal 
degree  (see  Fig.  65),  the  denudation  should  be  made  high  enough  on 
either  side  to  make  sure,  if  possible,  to  unite  the  loose  ends  of  the 
bulbo-cavernosus  muscle.     To  do  this  the  original  scar  tissue  should 


G.T\tV^^^^^^^- 


Fig.  70. — Tissue  forceps. 


not  be  taken  as  a  guide  in  vivifying  the  parts.  On  the  contrary, 
the  vivifying  should  be  carried  upward  on  either  side  to  within  an 
inch  or  less  of  the  lower  side  of  the  vestibule.  In  this  condition 
there  is  usually  prolapsus  of  the  posterior  vaginal  wall,  and  when 
such  is  the  case  the  denudation  should  be  carried  upwai-d  a  little 
higher. 

The  instruments  for  denuding  the  parts  are  a  number  of  sponges 
fixed  in  holders,  a  tissue  forceps  (see  Fig.  70),  and  Emmet's  curved 


scissors,  four  in  number,  two  with  lesser  curves  and  two  with  greater 
(see  Figs.  71  and  72).  These  instruments  can  not  be  described ; 
they  must  be  seen  to  be  understood. 


INJURIES  TO   THE   PELVIC   FLOOR. 


145 


The  method  of  operating  is  as  follows  :  The  jMtient  is  placed  upon 
the  operating-table  in  the  lithotomy  position,  and  the  limbs  held  in  a 


Clover  crutch  or  a  sheet  arranged  according  to  Dickinson's  method. 
An  assistant  on  each  side  separates  the  labia  to  fully  expose  the 
parts  ;  the  operator,  seated  in 
front  of  the  patient,  seizes 
the  tissues  with  the  forceps 
on  the  left  side  as  high  up 
as  the  denudation  should  ex- 
tend, and  with  the  scissors 
removes  a  strip  at  the  junc- 
tion of  the  skin  and  mucous 
membrane  across  to  a  corre- 
sponding point  on  the  right. 
The  end  of  the  strip  should 
be  left  attached,  the  other 
scissors  taken,  and  the  strip 
continued  back  to  the  left 
again.  In  this  way  the  con- 
tinuous strip  may  be  taken 
out  from  one  side  to  the  oth- 
er and  back  again  until  the 
wliole  surface  is  denuded. 
The  three  figures  will  give 
a  better  idea  of  the  mode  of 
procedure  than  this  descrip- 
tion. 

In  case  there  is  prolapsus 
of  the  vagina — and  it  is  there- 
fore  necessary   to  carry  the 
denudation  high  up  on  the  vaginal  wall — the  scissors  with  the  greatest 
curve  should  be  used  at  that  part  of  the  procedure. 

When  the  whole  surface  has  been  denuded  in  the  manner  de- 
scribed, it  is  necessary  to  make  sure  that  the  edges  of  the  wound 
11 


First  step ;    denudation  begun. 


146 


DISEASES   OF   WOMEN. 


are  straight  and  alike  on  both  sides,  and   that  the  surface  is  smooth. 
This  can  be  accompHshed  by  causing  the  assistants  to  put  the  parts 

upon  the  stretch,  when  care- 
ful sponging  will  show  any 
irregularity  which  needs  to 
be  trimmed  off.  By  passing 
the  linger  over  the  fresh  sur- 
face, any  scar  tissue  that  re- 
mains can  be  detected  by  its 
density  and  resistance  com- 
pared with  the  softness  and 
elasticity  of  the  normal  tissue. 
At  this  stage  of  the  op- 
eration attention  should  be 
given  to  haemorrhage.  If 
there  are  any  spurting  vessels 
in  the  wound  they  should 
be  controlled  by  suture  or 
ligature.  Fortunately,  when 
such  vessels  are  encountered 
they  are  generally  at  the  up- 
per margin  of  the  w^ound, 
and  may  be  controlled  by 
passing  a  fine  suture  through 
the  mucous  membrane  of  the 
vagina  and  under  the  ves- 
sel and  then  tying  it  tight 
enough  to  stop  the  bleeding. 
This  has  been  already  noticed  under  the  head  of  general  obser- 
vations. 

Next  in  order  comes  the  introduction  of  the  sutures,  and  just 
here  it  may  be  stated  that  for  all  plastic  operations  I  use  silk  sutures 
prepared  as  follows  :  The  ordinary  braided  silk  is  immersed  five  or 
six  hours  in  wax  containing  six  per  cent  of  carbolic  acid  and  six  per 
cent  of  salicylic  acid;  The  wax  is  kept  all  the  time  at  a  tempera- 
ture high  enough  to  licpiefy  it.  Tliis  long  immersion  in  the  melted 
wax  is  necessary  to  thoroughly  saturate  the  silk.  When  this  is  ac- 
complished, the  silk  is  drawn  through  a  carbolized  sponge  to  remove 
any  excess  of  the  wax.  It  is  then  put  on  a  reel  which  is  placed  in  a 
close-stoppered  bottle  and  kept  until  required.  Nos,  4  and  5  are  the 
sizes  used  ;  No.  5  for  the  lower  suture  and  No.  4  for  the  upper  ones. 
The  needles  employed  are  like  the  ordinary  darning  needles,  but 


Fig.  74. — Second  step ;    continuing  the  strip. 


INJURIES  TO   THE   PELVIC   FLOOR. 


147 


curved.  The  larger  needles  are  armed  with  No.  5  thread  and  the 
smaller  with  No.  4. 

To  manipulate  these  needles  it  is  necessary  to  have  a  suitable 
forceps,  and  for  this  I  have 
devised  the  instrument  rep- 
resented by  Fig.  76.  It  is  a 
double  forceps.  The  central 
portions  of  the  two  blades 
wliich  form  the  handles  are 
made  of  spring  steel.  The 
halves  cross  each  other  at 
about  an  inch  from  each  end 
to  form  the  jaws.  At  one 
end  the  jaws  are  file-faced  on 
the  upper  tip  and  grooved  on 
the  lower;  at  the  opposite 
end  the  jaws  are  copper-faced. 
The  latter  are  used  to  grasp 
the  point  of  the  needle  in 
drawing  it  through.  The 
elastic  spring  of  the  handle 
portion  opens  the  jaws  at 
each  end,  the  needle  is  intro- 
duced into  the  desired  groove, 
the  handle  is  grasped,  which 
closes  the  jaws  and  holds  the 
needle  perfectly  immovable, 
no  matter  how  much  pressure 
may  be  brought  to  bear  upon 
it.    When  the  jaws  are  closed 

there  is  a  stop-catch  that  holds  the  two  halves  of  the  handle  together 
and  keeps  a  firm  hold  upon  the  needle.  The  needle  is  carried  into 
the  tissues  while  it  is  held  by  the  grooved  and  file-faced  jaw  ;  it  is 


Fig   75. — Vivifying  complete ;  the  vaginal  su- 
tures on  one  side  are  inserted. 


Fig.  16.—  Needle-forceps. 


then  unfastened  by  drawing  back  the  catch,  the  forceps  is  reversed, 
and  the  point  of  the  needle  seized  in  the  copper-faced  jaws  and 
withdrawn.     The  advantage  of  the  copper-faced  jaws  is  that  they 


148 


DISEASES   OF   WOMEN. 


Fig.  77. 


seize  the  point  of  the  needle  lirmly  enough  to  draw  it  through  the 

tissues  without  injuring  the  point — a  vahiable  feature  in  such  an 

instrument. 

The  sutures  are  introduced  as  follows :  The  needle — placed  in 

the  forceps  at  right  angles  to  it,  should  be  entered  in  the  skin 
exactly  at  the  edge  of  the  wound  at  the  lowest  external 
angle  of  the  denuded  tissue.  It  is  then  passed  outward 
deep  into  the  tissues,  then  curved  round  in  the  tissues  in 
front  of  the  rectum  and  deep  into  the  tissue  of  the  other 
side,  and  made  to  emerge  at  a  point  corresponding  to  the 
one  where  it  was  entered.  If  this  is  properly  done,  no 
part  of  the  suture  will  be  seen.    Its  position  in  the  tissues 

will  be  as  represented  in  Fig.  YY.     The  dotted  line  represents  the 

suture  which  describes  a  circle,  and  the  straight  line  shows  the  sides 

of   the   wound  as  they   are 

brought  together  where  the 

suture  is  tied.      Sometimes 

when  the  tissues  are  rigid  it 

is  difficult  to  introduce  the 

first  suture  with  one  sweep 

of    the  needle.      It  is  then 

better  to  pass  the  needle  in 

through  half  of  the  vivified 

portion,  to  draw  it  out  and 

re-insert  it  at  the  same  point, 

and  carry  it  around  through 

the   other  side.     If  there  is 

sufficient  tissue  between  the 

base  of  the  vivified  part  and 

the  rectum,  the  second  and 

third  sutures  may  be  intro- 
duced   like    the   first  ^ — each 

one  being  passed  at  a  higher 

point.      The    fourth    suture 

(see   Fig.   78)  is  introduced 

through  the  side.     It  is  then 

carried  through  about  three 

eighths  of  an  inch  of  the  vivi- 
fied  portion  of  the   vaginal 

wall,  and  then  passed  through 

the  other  side.    The  last  suture  is  passed  through  both  sides,  as  shown 

in  Fig.  80,  the  position  of  the  sutures  being  viewed  in  profile. 


Fig.    78. — The    stitches    in  ])lace ;    the   vaginal 
sutures  tied. 


INJURIES   TO   THE   PELVIC   FLOOR, 


149 


When  more  than  live  sutures  are  used,  the  fifth  is  passed  hke 
the  fourth,  only  a  Httle  above  it.  Most  operators  introduce  the  in- 
dex-finger into  the  rectum,  to  guide  the  introduction  and  passing  of 
the  needle.  This  should  not  be  done  under  any  circumstances,  be- 
cause, by  so  do- 
ing, the  rectal 
wall  is  crowded 
forward,  and  is 
sure  to  be  includ- 
ed in  the  suture, 
and,  besides,  it  is 
a  violation  of  the 
rules  of  antisep- 
tic surgery  to  op- 
erate   with   dirty 

fino-ers,  ■^'^^-  '^^- — Laceration  with  rectocele.  (The  Fig.  80. — Perineal 

^  dotted  line  gives  the  normal  location  body     restored. 

in  many  cases  of  perineal  body.)  (Profile  view.) 

there  is  very  little 

tissue  left  in  the  perineal  body  after  the  vivifying  is  completed. 
The  muscular  coat  of  the  vaginal  wall  having  become  atrophied,  or 
torn  fi-om  its  attachments  to  the  floor  of  the  pelvis,  there  is  only 
the  mucous  membrane  left,  and,  when  that  is  removed  in  denuding 
the  parts,  the  wall  of  the  rectum  is  all  that  is  left  above  the  skin 
and  sphincter-ani  muscle.  When  such  is  the  case,  the  first  suture 
only  should  be  carried  through  the  tissue,  as  already  described ;  the 
others  should  be  introduced  as  shown  in  Fig.  78. 

The  great  advantage  of  this  is,  that  the  sides  of  the  wound  are 
brought  together  in  front  of  the  rectum,  the  place  where  the  perineal 
body  should  be.  Furthermore,  the  sutures  introduced  in  this  way 
avoid  the  rectal  wall — a  very  important  desideratum,  as  we  know 
from  the  fact  that  when  any  of  the  sutures  are,  intentionally  or  by 
accident,  passed  into  the  wall  of  the  rectum,  they  cause  much  pain 
and  rectal  tenesmus,  and  greatly  distress  the  patient,  especiallj^  when 
the  bowels  move.  When  the  sutures  are  all  in  place,  the  wound 
should  be  carefully  cleansed  of  all  blood-clots,  and,  if  there  is  still 
some  oozing  of  blood,  traction  should  be  made  upon  the  sutures ; 
if  that  controls  the  bleeding,  the  sutures  should  be  tied  in  the 
ordinary  way.  While  they  are  being  tied  the  sides  of  the  pelvic 
floor  should  be  pushed  up  by  the  assistants,  to  bring  the  wound 
together. 

The  after-treatment  and  other  points,  such  as  the  removal  of  the 
sutures,  will  be  brought  out  in  the  history  of  the  following  cases : 


l^Q  DISEASES  OF   WOMEN. 

Case  of  Central  Laceration  extending  to  the  Sphincter  Ani ;  Uncom- 
plicated.— The  patient,  a  spare,  small  woman,  in  good  general  health. 
She  had  been  married  nine  years,  and  had  one  child  eight  years  old. 
Her  labor  was  easy  and  rapid,  and  her  convalescence  uninterrupted, 
excepting  that  she  had  a  leucorrhoea  which  began  after  the  lochia 
stopped,  and  continued  until  the  time  when  she  sought  medical  ad- 
vice. Her  menses  returned  ten  months  after  her  confinement  and 
one  month  after  her  child  was  weaned.  Six  years  after  her  conline- 
ment  she  overtaxed  her  strength,  and  then  her  leucorrhoea  became 
more  profuse,  and  she  began  to  suifer  from  backache  and  slight  pel- 
vic tenesmus,  especially  upon  standing  or  walking.  She  was  consti- 
pated, but  in  all  other  respects  was  well.  She  sought  medical  advice 
because  of  these  symptoms  and  her  sterility.  An  examination  showed 
a  laceration,  but  no  other  injury  to  the  pelvic  floor.  The  posterior 
and  lateral  parts  of  the  floor  were  well  sustained,  and  there  was  very 
little  separation  of  the  sides  of  the  laceration.  There  was  commen- 
cino-  prolapsus  of  the  posterior  vaginal  wall,  luit  it  was  only  apparent 
upon  separating  the  labia  and  causing  the  ])atient  to  cough  or  make 
downward  pressure.  The  uterus  was  below  its  normal  elevation,  but 
not  changed  in  its  axis.  The  leucorrhoea  was  due  to  a  cervical  ca- 
tarrh, which  promptly  yielded  to  treatment. 

Five  days  after  a  menstrual  period  her  bowels  were  freely  moved 
in  the  morning  by  a  dose  of  pulv.  glycyrrhizse  comp.,  given  at  bed- 
time the  night  before.  On  the  following  evening  the  l)Owels  moved 
spontaneously,  and,  an  hour  later,  an  enema  of  borax  and  warm 
water  was  given  to  wash  out  the  rectum.  Early  next  morning 
the  vagina  and  pudendum  were  thoroughly  cleansed  and  disin- 
fected and  she  was  anaesthetized  with  ether,  and  the  operation 
was  performed  according  to  the  method  already  described.  The 
bleeding  was  easily  controlled  by  the  sutures.  A  small  pledget  of 
marine  lint  was  placed  over  the  wound  and  the  knees  bandaged  to- 
gether. Soon  nausea  followed,  but  no  vomiting,  and  late  in  the  even- 
ing she  was  comfortal)le,  having  only  a  feeling  of  slight  burning  in 
the  region  of  the  wound.  She  took  a  small  cup  of  tea,  and  slept 
several  hours  during  the  night. 

Next  day  she  liad  milk,  soup,  and  gruel.  The  catheter  was  used 
for  the  first  forty-eight  hours,  and  after  that,  when  necessary,  she  was 
rolled  over  upon  her  face,  and,  with  a  bed-pan  placed  under  her,  she 
urinated  without  further  help.  On  the  morning  of  the  third  day 
she  took  a  Seidlitz  powder,  and  at  noon  an  enema  of  castile  soap  and 
water,  which  moved  the  bowels  freely  and  easily.  After  this  the 
bowels  were  moved  dailv  witli  an  enema  and  she  had  her  usual  food. 


INJURIES  TO  tup:  pelvic  floor. 


151 


The  marine  lint  was  kept  upon  the  outside  of  the  wound  for  five 
days,  changing  it  daily.  There  was  no  discliarge  from  the  vagina 
or  wound.  There  were  no  vaginal  injections  used, 
and  the  wound  was  not  washed  at  any  time.  In 
fact,  after  the  fifth  day  she  had  no  local  treatment. 


Fig.  81. — Scissors  for  removing  sutures. 

On  the  eighth  day  the  sutures  were  removed  in 
the  following  way  :  She  was  placed  in  Sims's  position  on  the  bed ; 
the  nurse  separated  the  nates,  which  exposed  all  the  sutures  without 
making  any  traction  upon  the  parts;  each  suture  was  seized  with  a 
forceps,  and,  with  the  tenaculum  blade  of  the  scissors,  one  side  of 
the  thread  was  caught  up  and  divided.  Fig.  81  shows  the  scissors 
used  for  the  removal  of  sutures.  It  answers  the  purpose  well,  and 
guards  against  clipping  off  both  ends  and  leaving  the  suture  in  the 
tissues,  an  accident  which  not  unfrequently  happens.  This  method 
of  removing  the  sutures  is  very  much  simpler  than  trying  to  remove 
them  with  the  patient  upon  the  back. 

The  patient  was  kept  in  bed  until  the  twelfth  day  after  the  opera- 
tion, but  during  that  time  she  was  allowed  to  change  her  position 
from  the  back  to  either  side  without  help.  On  the  thirteenth  day 
she  was  permitted  to  sit  in  a  chair,  and  on  the  fifteenth  day  she  was 
allowed  to  begin  to  walk. 

Two  months  after  the  operation  she  was  examined,  and  the  space 
between  the  rectum  and  vagina  was  found  to  be  normal  to  the  touch 
— i.  e.,  the  lines  represented  by  the  lower  portion  of  the  posterior 
vaginal  wall  and  the  outer  surface  of  the  pelvic  floor, 
running  from  before  backward,  formed  an  angle  as 
represented  in  the  accompanying  diagram. 

Furthermore,  when  the  introitus  vaginae  was  re- 
tracted with  a  Sims's  speculum   and   the   instrument 
removed,  the  muscles  promptly  contracted  and  firmly 
closed  the  vagina,  showing  that  the  muscles  had  been  restored.    This 
I  consider  to  be  the  only  reliable  evidence  of  the  success  of  this 
operation. 

Subcutaneous  Laceration  in  the  Median  Line. — The  first  step  in 
the  operation  for  this  injury  is  to  make  an  incision  in  the  skin  from 
the  posterior  commissure  down  to  the  sphincter-ani  muscle,  and  then 
remove  the  scar  in  the  cellular  tissue  and  proceed  as  in  the  com- 


152  DISEASES   OF    WOMEN. 

plete  laceration  just  described.  In  case  there  is  prolapsus  of  the  pos- 
terior vaginal  wall,  the  redundant  skin  and  mucous  membrane  should 
be  removed  and  the  vivifying  of  the  tissues  completed  by  removing 
all  scar  tissue. 

Laceration  of  the  Pelvic  Floor,  Sphincter-Ani  Muscle,  and  Recto- 
Vaginal  Septum. — In  this  extensive  injury,  in  which  the  laceration 
of  the  walls  of  the  rectum  and  vagina  extends  upward  bevond  the 
internal  sphincter  ani,  it  is  necessary  to  restore  the  septum  before 
operating  upon  the  perinaeum.  As  a  rule,  the  laceration  does  not 
extend  beyond  the  sphincters,  and  the  parts  can  all  be  restored  at 
one  operation,  but  in  the  rare  injury  now  under  consideration  two 
separate  operations  are  required.  I  will  describe  lirst  the  operation 
for  restoration  of  the  septum.  The  patient  should  be  placed  in  the 
lithotomy  position,  and  the  anterior  wall  of  the  vagina  elevated 
by  a  Sims's  or  otlier  retractor,  which  exposes  the  parts  to  be  treated. 
The  tissues  on  each  side  of  the  laceration  are  vivified  well  out 
on  the  vagina,  in  order  to  obtain  a  broad  surface  for  coaptation. 
Only  enough  of  the  mucous  membrane  of  the  rectum  is  removed 
to  dispose  of  the  scar  tissue  that  may  be  present.  Silk  sutures 
are  introduced  wdth  a  round-pointed,  curved  needle,  such  as  Emmet 
uses  for  vesico-vaginal  fistula.  The  needle  should  be  introduced 
at  the  outer  edge  of  the  vivified  surface  of  the  vaginal  mucous 
membrane  and  be  carried  deep  into  the  tissues,  and  should  emerge 
just  within  the  edges  of  the  rectal  mucous  membrane.  By  refer- 
ring to  Fig.  82  an  idea  may  be  obtained  of  the  sutures  in  posi- 
tion, with  this  difference,  that  in  this  operation  silk  sutures  are 
used,  and  are  tied  upon  the  vaginal  side,  whereas  in  the  operation 
of  restoring  the  sphincter-ani  muscle  and  perinaeum,  catgut  sutures 
are  employed,  and  these  are  tied  upon  the  rectal  side.  The  in- 
troduction of  the  sutures  is  begun  above,  and  each  one  tied  when 
introduced. 

The  sutures  should  be  No.  8  silk,  and  not  more  than  an  eighth 
and  a  sixteenth  of  an  inch  apart.  They  should  be  removed  on  the 
eighth  day,  and  one  month  allowed  to  elapse  before  the  next  opera- 
tion is  ])erformed,  in  order  to  give  tlie  })arts  a  chance  to  become 
firmly  united. 


OPERATION   FOR   THE   RESTORATION   OF   THE    SPHINCTER 
ANI   AND   PERINEUM. 

It  has  been  already  stated   that  the  chief  object  of  all  plastic 
operations  upon  the  ])clvic  floor  should  be  to  restore  the  muscles 


INJURIES   TO   THE   PELVIC   FLOOR. 


153 


that  have  been  injured.  This  is  pre-eminently  so  in  the  operation 
to  be  described,  because  the  sphincter  ani  is  the  most  difficult  to 
restore,  and  the  results  of  failure  are  so  apparent  that  neither  the 
surgeon  nor  patient  can  possibly  believe  that  the  operation  is  a 


Fig.  82. —  Complete  laceration  of  the  periuseum  and  sphincter  ani.  The  depressions  on 
either  side  of  the  rectal  opening  show  the  separated  ends  of  the  torn  sphincter. 
Between  the  two  runs  a  thin  bridge  of  dense  scar  tissue.  The  rectum  is  drawn 
toward  the  pubic  arch  by  a  strong  levator.  Moderate  cystocele  and  rectocele  are 
present. 

success  when  it  is  not — a  delusion  often  indulged  in  regarding 
the  plastic  operations  to  repair  the  lesser  injuries  of  the  pelvic 
floor. 

In  order  to  comprehend  the  position  and  relations  of  the  surfaces 


154 


DISEASES  OF   WOMEN. 


to  be  viv^lied,  it  must  be  borne  in  mind  that  when  the  sphincter  ani 
is  ruptured  the  severed  ends  are  drawn  outward  and  backward  by 
the  retraction  of  the  muscle  until  they  lie  on  either  side  nearly  on  a 
line  with  the  posterior  walls  of  the  rectum.     This  may  be  better 


Fig.  83. — Complete  laceration  of  pi'iin;i\nii.  Dciiinliitiuii  ronipletcd.  Here  the  vulva 
is  shown  drawn  apart  much  more  widely  than  in  Fijr.  8tl.  The  flap  (R)  left  from 
the  rectocele  is  raised.  The  scar  tissue  between  the  sphincter  ends  has  been  re- 
moved.    The  depressions  indicate  the  ends  of  the  sphincter. 


understood  by  referrinir  to  ¥\s;.  82.  The  depressions  on  either  side 
of  the  anus  are  the  ends  of  the  mn.scle  which  are  drawn  down  below 
the  surface. 

The  process  of  vivifying  should  be  begun  by  seizing  the  end  of 
the  muscle  on  the  patient's  left.     AVith  the  scissors  a  strip  of  tissue 


INJURIES  TO   THE   PELVIC   FLOOR.  I55 

should  be  removed  from  tliat  point  around  the  tissues  between  the 
rectum  and  vagina,  and  downward  and  outward  to  and  includincr 
tlie  end  of  the  muscle  on  the  right.  AYhen  this  is  done,  it  will  some- 
times be  found  that  the  softer  tissues  rise  above  the  depressed  end 
of  the  muscle,  so  that  a  fossa  is  formed  on  each  side.  Should  this 
occur,  more  of  the  most  prominent  tissue  should  be  removed.  The 
denudation  is  then  carried  upward  upon  each  side  to  the  point 
where  the  laceration  began.  If  there  is  much  relaxation  of  the 
rectal  and  vaginal  walls,  the  denudation  may  extend  even  higher  on 
the  sides. 

At  this  stage  of  the  vivifying  there  are  two  broad  denuded  sur- 
faces (one  on  each  side),  connected  by  an  isthmus  formed  by  the  recto- 
vaginal walls.  In  this  septum  all  scar  tissue  should  be  cut  away,  and 
then  the  rectal  and  vaginal  walls  should  be  separated  with  the  handle 
of  a  scalpel  or  blunt-pointed  scissors.  The  object  of  this  dissection 
is  to  give  a  broader  surface  to  be  united,  and  to  permit  the  vaginal 
wall  to  be  raised  up  and  attached  to  the  inner  side  of  the  perineal 
body,  as  it  is  called.  When  the  vivifying  is  completed  the  parts 
appear  as  represented  in  Fig.  83.  There  are  ordinarily  two  sets  of 
sutures  used,  one  to  coaptate  the  rectal  wall  and  sphincter-ani  muscle, 
and  the  other  to  do  the  same  for  the  perinseum.  The  rectal  sutures 
are  introduced  first.  I  used  'No.  2  catgut  and  the  curved  Emmet 
needle.  The  needle  is  entered  at  the  margin  of  the  rectal  nmcous 
membrane  on  the  patient's  right  side,  and  is  carried  upward  and  out- 
ward in  the  tissues  about  a  quarter  of  an  inch.  It  is  then  withdrawn 
and  entered  on  the  left  side,  and  brought  out  in  a  manner  corre- 
sponding to  the  course  which  the  needle  traversed  in  the  right  side. 
This  leaves  the  ends  of  the  sutui*es  to  be  tied  on  the  inside  of  the 
rectum. 

In  introducing  the  first  perineal  suture,  the  point  of  the  needle 
should  be  entered  at  the  inner  and  lower  point  of  the  vivified  sur- 
face, then  carried  outward  around  the  end  of  the  muscle,  then  in- 
ward through  the  recto-vaginal  wall,  and  finally  around  the  other 
end  of  the  muscle  to  a  point  directly  opposite  the  one  where  the 
needle  was  introduced.  This  requires  skill  and  practice,  and  is  often 
difficult ;  and  I  have  found  it  easier  to  pass  the  needle  around  the 
ends  of  the  muscle  and  bring  it  out  in  the  median  line,  reintroduce 
it,  and  carry  it  around  the  other  end  of  the  muscle.  The  objection 
made  to  this  method  is  that  the  central  portion  of  the  suture  is  ex- 
posed, but  the  suture  is  completely  buried  in  the  tissues  when  it 
is  tied.  Certainly  it  is  better  to  introduce  the  first  suture  accurately 
in  this  way  than  to  attempt  the  more  difficult  way  and  fail  to  get  it 


156 


DISEASES  OP   WOMEN. 


right,  a  result  usual  to  those  who  are  not  accustomed  to  this  operation. 
The  second  suture  may  be  introduced  in  the  same  way.  The  remain- 
ing sutures  are  employed  in  the  way  described  in  the  operation  for 
restorins:  the  laceration  in  the  first  deg^ree.  Fiars.  84  and  85  show 
the  sutures  in  place. 

Certain  changes  are  necessary  to  be  made  in  the  details  of  the 
operation  in  those  rare  cases  in  which  the  laceration  of  the  recto- 


FlG.  84. — Complete  laceration  of  i)ciin;i'uiii  throut^li  s|>liiiicter.     The  sutures  in  the  rectal 
wall  introducotl.     For  the  sake  of  cli'arness  soiuo  have  been  omitted. 

vao-inal  septum  has  extended  so  high  up  that  an  operation  for  its 
restoration  is  necessary  before  restoring  the  sphincter-ani  muscle  and 
the  perin5T3um.  Another  condition  recjuiring  similar  treatment  is 
found  in  cases  in  which  the  scjitum  has  been  extensively  lacerated, 


INJURIES   TO   THE   PELVIC   FLOOR. 


157 


but  has  united  by  intervening  scar  tissue,  which  has  to  be  removed 
to  secure  a  perfect  restoration. 

Under  such  circumstances,  and  also  in  cases  in  wlncli  the  rectal 
and  vaginal  walls  can  not  be  separated  by  dissection,  it  is  better  to 
unite  the  vaginal  wall  in  the  median  line  by  a  special  row  of  sutures 
running  parallel  to  the  axis  of  the  vagina.  In  such  cases  three  sets  of 
sutures  are  necessary :  One  to  unite  the  rectal  wall,  one  to  unite  the 


Fig.  85. — The  rectal  sutures  have  been  tied  on  the  rectal  side  and  the  ends  cut  short. 
The  remaining  sutures  are  in  place.  The  flap  from  the  rectocele  is  lifted  by  a 
tenaculum. 


perinseum,  and  one  to  unite  the  vaginal  wall.  In  performing  this 
modified  operation,  I  usually  vivify  the  edges  of  the  laceration  of  the 
septum  the  entire  length  and  then  introduce  the  rectal  sutures  and  be- 


158  DISEASES   OF   WOMEN. 

fore  tying  tliem  vivify  all  the  rest  of  the  parts  to  be  united.  The 
stitches  are  introduced  into  the  vaginal  wall  and  the  perineal  stitches 
placed  last.  The  patient  is  put  into  Sims's  position  and  the  rectal 
sutures  are  tied.  She  is  replaced  upon  the  back  and  the  vaginal 
sutures  are  tied,  and  lastly  those  in  the  pelvic  floor. 

I  have  obtained  the  very  best  results  from  this  method  of  opera- 
ting, and  in  suitable  cases  prefer  it  to  all  others.  Further  details  of 
the  operations  will  be  brought  out  in  the  following  history  of  cases : 
Typical  Case  of  Laceration  extending  through  the  Sphincter  Ani. — 
The  patient  was  twenty-six  years  old  when  she  was  confined  with 
her  first  child.  The  labor  was  tedious,  and  she  was  delivered,  with 
forceps,  of  a  very  large  child,  which  died  during  delivery.  She 
made  a  rather  slow  recovery,  owing  to  the  extensive  injury  to  the 
floor  of  the  pelvis.  Five  months  after  confinement  I  saw  her  for 
the  first  time.  She  was  then  in  very  good  health,  but  suffered  pain 
in  the  region  of  the  injury,  especially  when  she  walked,  and  she  had 
very  little  control  of  the  rectum.  When  constipated,  she  suffered 
very  little ;  but,  when  the  bowels  were  free  and  when  there  was 
flatulence,  she  was  obliged  to  remain  secluded. 

I  found  that  the  laceration  involved  the  sphincter-ani  muscle, 
and  evidently  had  extended  upward  into  the  wall  of  the  rectum  and 
vagina ;  but  union  had  taken  place,  by  a  little  intervening  scar  tis- 
sue, down  to  the  sphincter,  or  within  a  quarter  of  an  inch  of  it.  The 
muscles  of  the  pelvic  floor,  excepting  the  sphincter  and  transver- 
sus  peringei,  acted  well,  and  held  the  divided  sides  well  up.  The 
end  of  the  rectum  was  also  drawn  upward  and  forward,  so  that  the 
distance  from  the  vestibule  to  the  posterior  margin  of  the  anus  was 
less  than  normal.  This  brought  the  posterior  wall  of  the  vagina  up 
to  the  anterior,  so  that  the  vagina  was  closed.  It  was  only  by  plac- 
ing the  finger  in  the  rectum  and  pressing  it  backward  that  the  full 
extent  of  the  laceration  became  apparent.  She  was  constipated,  and 
her  tongue  slightly  coated,  at  this  time.  Pil.  hydrarg.,  gr.  x,  and 
pulv.  ipecac,  gr.  j,  were  given  at  bedtime,  and  a  wine-glass  of  Hun- 
yadi-Jauos  water  an  hour  before  breakfast  next  morning.  This 
moved  the  bowels  freely,  and  they  were  kept  free  for  the  subsequent 
two  weeks  with  the  following : 

Fluid  extract  of  pod(»j)hyllum 3  j  I 

Tincture  of  colocynth 3  ij  5 

Tincture  of  belladonna 3  j  ; 

Glycerin 3  ss. ; 

Syrup  of  acacia  and  compound  tincture  of  cardamom, 
of  each 5  j- 


INJURIES   TO    THE    PELVIC    FL(XJR.  159 

A  teaspoonful  of  this  noon  and  evening  before  meals.     When  this 
acted  too  freely,  only  one  dose  was  given. 

During  these  two  weeks  the  nurse  passed  the  finger  every  day 
into  the  rectum  and  pressed  the  parts  back  toward  the  coccyx,  main- 
taining the  traction  steadily  for  several  minutes.  This  was  done  for 
the  purpose  of  restoring  the  elasticity  of  the  tissues,  and  also  elon- 
gating the  divided  sphincter  muscle  as  much  as  possible.  Menstrua- 
tion then  began,  and  no  further  local  treatment  was  employed  mitil 
after  it  stopped,  when  it  was  resumed.  Four  days  after  the  menses 
ceased,  the  operation  was  performed  in  the  prescribed  way,  silk 
sutures  being  used.  For  twenty-four  hours  before  the  operation, 
and  for  three  days  after,  the  patient  had  only  fluid  food — beef-tea, 
strained  soups,  whey,  and  water.  After  the  third  day,  peptonized 
milk,  strained  oatmeal  and  barley  gi*uels,  and  raw  oysters  were  added 
to  the  diet  list. 

There  was  sufficient  pain  during  the  first  three  days  to  require 
ten  drops  of  liquor  opii  comp.  to  be  taken  every  four  hours.  On 
the  fourth  day  she  suffered  from  flatulence,  which  was  relieved  by 
catheterizing  the  rectum,  using  a  silver  catheter ;  this  had  to  be  re- 
peated the  following  day.  On  the  eighth  day  (and  before  the  su- 
tures were  removed)  half  an  ounce  of  sulphate  of  magnesia  in 
peppermint-water  was  given  before  breakfast  and  toward  noon ; 
when  the  patient  felt  the  bowels  inchned  to  move,  half  a  pint  of 
solution  of  ox-gall  and  water  were  used  as  an  enema.  When  this 
had  been  retained  about  twenty  minutes,  the  nurge  assisted  the 
evacuation  of  the  bowels  by  making  pressure  upon  each  side  of  the 
wound  opposite  the  hrst  suture,  and,  with  the  index-finger  of  the 
other  hand  in  the  vagina,  she  made  gentle  and  interrupted  pressure 
downward  and  outward.  In  this  way  it  was  hoped  that  the  rectum 
would  be  evacuated  without  disturbing  the  wound.  There  was  not 
the  slightest  trace  of  haemorrhage,  which  gave  reason  for  believing 
that  no  harm  had  been  done. 

On  the  ninth  day  all  the  sutures  were  removed,  and  on  the  tenth 
day  the  bowels  were  moved  in  the  same  way  as  before.  During  all 
this  time  the  catheter  was  used  to  draw  the  urine.  After  this  the 
patient  was  permitted  to  urinate  in  the  prone  position.  Every  second 
day  until  the  twentieth  the  bowels  were  moved,  the  same  care  being 
taken  by  the  nurse  to  guard  the  wound  during  the  evacuation.  On 
the  twentieth  day  the  wound  was  carefully  examined,  and  there  was 
apparently  perfect  union  throughout,  including  the  mucous  mem- 
brane. The  function  of  all  the  muscles  of  the  pelvic  floor  was  re- 
stored, except  that  of  the  sphincter  ani.     The  function  of  that  mus 


160 


DISEASES   OF    WOMEN. 


cle  was,  however,  sufficiently  restored  to  give  the  rectum  retaining 
power,  but  it  did  not  act  as  a  perfect  sphincter  muscle.  When  it 
acted,  the  contraction  was  not  equally  toward  the  center,  but  rather 
toward  the  point  of  rupture  that  had  been  restored.  The  posterior 
portion  of  the  perineal  body  acted  like  a  fixed  point,  toward  which 
the  muscle  contracted.  I  am  inclined  to  believe  that  this  is  the  best 
result  that  can  be  obtained  by  this  operation.  After  the  new  repara- 
tive tissue  which  is  developed  during  healing  has  fully  contracted, 
the  function  of  the  muscle  becomes  more  nearly  restored.  Indeed, 
it  is  in  many  cases  quite  perfect  so  far  as  controlling  the  rectum  is 
concerned,  but  it  rarely,  if  ever,  acts  exactly  as  it  did  before  injury 
— i.  e.,  by  a  perfect  concentric  contraction. 

A  Case  illustrating  Partial  Failure  of  the  Operation;  a  Second 
Operation  completing  the  Cure. — The  patient  was  thirty-five  years 
old,  and  had  had  three  children.  The  youngest  was  eighteen  months 
old  at  the  time  when  this  history  was  taken.  Her  first  labor,  five 
years  and  a  half  ago,  was  comj^licated.  The  patient  stated  that  the 
doctor  in  attendance  said  that  there  was  a  shoulder  presentation,  that 
the  child  was  turned  and  delivered  feet  first,  and  that  the  forceps 
was  used  to  deliver  the  after-coming  head.  From  that  time  onward 
she  had  no  control  of  the  rectum,  and  the  only  way  she  w^as  able  to 
take  care  of  herself  was  by  being  extremely  constipated,  the  bowels 
never  moving  except  in  response  to  medicine,  a  dose  of  which  she 
usually  took  about  once  ever}'  week.  The  extent  of  the  injury  was 
exactly  like  the  case  last  given,  excepting  that  there  was  union  of  a 
thin  band  of  vaginal  mucous  membrane,  which  extended  outward  to 
the  upper  margin  of  the  sphincter-ani  muscle.  There  were  also  two 
hiTemorrhoidal  tumors,  formed  by  hyperplasia  of  the  rectal  mucous 
membrane,  located  at  each  side  of  the  anus.  These  haemori'hoids, 
which  are  not  uncommon  in  this  injury,  were  removed  one  month 
before  the  restoration  of  the  lacerated  parts  was  undertaken.  The 
mode  of  operating  was  by  seizing  the  tumors  in  a  Pean  forceps  and 
making  traction  sufficient  to  raise  the  mucous  membrane,  then  pass- 
ing the  haeniorrhoid-clamp  (Fig.  8G)  beneath  the  forceps,  and  slowly 


Fig.  so — Iltcinorrlioid  tlaiup. 


INJURIES   TO   THE    PELVIC    FLOOR.  161 

constricting  the  pedicle  by  tightening  the  clamp.  A  ligature  of 
prepared  silk  was  applied  to  the  pedicle  under  the  clamp.  The  for- 
ceps and  clamp  were  then  removed,  the  tumor  clipped  oft"  far  enough 
outside  of  the  ligatui-e  to  prevent  its  slipping,  and  the  stum])  touched 
with  carboHc  acid.  The  ligatures  came  oft  in  less  than  a  week,  leav- 
ing a  very  minute  spot  to  heal.  She  was  then  submitted  to  about 
the  same  preparatory  treatment  as  in  the  last  case  related,  and  the 
operation  was  performed  as  before  described.  The  diet  was  gruel 
and  peptonized  milk,  with  beef-tea.  On  the  second  day  half  an  ounce 
of  Roclielle  salt  was  given,  followed  in  three  hom's  by  an  enema  of 
half  a  pint  of  a  solution  of  ox-gall,  and,  one  hour  later,  a  large  ene- 
ma of  soap-suds.  This  did  not  move  the  bowels  ;  on  the  following 
morning  half  an  ounce  of  castor-oil  was  given,  and  in  the  afternoon 
the  enema  repeated  as  on  the  previous  day ;  the  enema  came  away, 
but  the  bowels  did  not  move.  The  next  day,  she  was  ordered  a 
mixture  composed  of  a  decoction  of  senna,  one  ounce  to  a  pint  of 
water,  with  one  ounce  of  Rochelle  salt.  Of  this,  two  ounces  were 
given  every  hour  until  she  had  taken  three  doses.  It  pi'oduced  a 
free  evacuation,  without  causing  pain  in  the  wound  or  doing  it  any 
harm.  The  mixture  was  repeated  in  the  same  way  with  a  like  effect, 
and  was  again  ordered  a  third  time,  but,  by  an  oversight  of  the  nurse 
(the  case  was  in  a  general  hospital),  it  was  not  given.  Another 
mistake  was  made  the  following  day,  the  nurse  giving  two  drachms 
in  place  of  two  ounces  of  the  medicine.  On  the  eighth,  day  after 
the  operation  the  medicine  was  given  correctly  ;  but,  when  the  bowels 
were  about  to  move,  the  nurse,  who  should  have  sujDported  the  parts, 
was  absent,  and  the  patient  got  out  of  bed  to  use  the  commode,  and 
had  a  free  movement,  attended  with  pain  and  some  bleeding.  Up  to 
this  time  the  wound  had  progressed  quite  well  in  healing,  but  that 
unfortunate  movement  of  the  bowels,  unaided  by  the  nurse,  tore  the 
ends  of  the  sphincter-ani  muscle  apart,  and  spoiled  the  operation  to 
that  extent.  On  the  tenth  day  the  sutures  were  removed.  There 
was  perfect  union,  excepting  the  ends  of  the  muscle.  The  opera- 
tion was  a  complete  failure,  so  far  as  its  main  object  was  concerned. 
She  was  kept  in  the  hospital  for  two  days  more,  when  it  was  found 
that,  although  her  bowels  were  easily  kept  regular — a  great  improve- 
ment on  her  former  state — she  had  very  little  more  control  of  the 
rectum  than  before  the  operation. 

Three  months  after  this  she  was  again  persuaded  to  try  to  obtain 

relief,  and  she  was  placed  under  the  care  of  a  more  competent  nurse, 

who  followed  directions  regarding  preparatory  treatment,  including 

the  manipulation  daily  of  the  sphincter  ani,  and  at  the  end  of  a  week 

12 


162  DISEASES  OF  WOMEN. 

another  operation  was  performed  to  restore  the  sphincter.  The 
stretchinor  of  the  muscle  backward  with  the  finder  in  the  rectum  as 
practiced  bj  the  nurse  was  more  effectual  than  in  cases  in  which  the 
rupture  is  complete.  The  part  of  the  pelvic  floor  which  was  restored 
by  the  operation  gave  some  support  to  the  severed  ends  of  the  sphinc- 
ter, so  that  when  traction  backward  was  made  the  muscle  became 
considerably  elongated ;  and  when  the  second  operation  was  under- 
taken the  parts  were  sufficiently  relaxed  to  facilitate  the  necessary 
manipulations. 

The  patient,  well  anaesthetized,  was  placed  in  Sims's  position,  a 
small  speculum  introduced  into  the  rectum  posteriorly,  and  traction 
made  backward,  while  with  a  strong  tenaculum,  fixed  in  the  margin 
of  the  anus  anteriorly,  the  ends  of  the  muscle  and  the  intervening 
tissues  were  brought  into  view.  The  end  of  the  muscle  of  the  left 
side  was  seized  in  the  tissue  forceps  and  denudation  made  from  the 
left  to  the  right  end  of  the  nmscle.  The  vivifying  included  both 
ends  of  the  muscle  and  extended  upward  on  the  anterior  rectal  wall 
about  half  an  inch.  The  sutures,  three  in  number,  were  introduced 
in  the  same  way  as  in  the  first  operation.  Some  trouble  was  ex- 
perienced in  curving  the  needle  around  through  the  tissues,  but  with 
the  aid  of  an  assistant,  who  passed  his  index-finger  into  the  vagina 
and  everted  the  rectum  in  front,  all  the  sutures  were  accurately  in- 
troduced. 

On  the  third  day  after  the  operation  a  dose  of  senna  and  salts 
was  given  in  the  morning,  and  at  noon  the  bowels  were  moved  in  a 
rather  novel  way.  An  apparatus  constructed  upon  the  principle  of 
that  used  by  Professor  Bigelow  for  expelling  fragments  of  stone 
from  the  bladder  was  employed  to  wash  out  the  contents  of  the  rec- 
tum (Fig.  87). 


Fig.  87. — a  is  a  hard-rubber  rectal  tube  bifurcated  at  b  c;  b,  wliieli  is  the  supply  tube, 
is  attached  to  a  fountain  syringe,  an<l  c  connects  with  the  evacuator,  composed  of  a 
soft-rubber  bulb,  with  an  escape  tul)e.  In  other  words,  it  is  a  large  I'cflux  catheter 
with  a  rubber  bulb  in  the  escape  tube  for  the  purpose  of  facilitating  the  outflow. 

Two  nurses  use  this  instrument  as  follows :  One  passes  the  tube 
into  the  rectum,  carefully  making  continuous  pressure  backward  to 
avoid  pressing  upon  the  edges  of  the  wound,  while  the  other  nurse. 


INJURIES  TO   THE   PELVIC   FLOOR.  163 

closing  the  escape  tube  and  opening  the  stop  in  the  fountain  syringe, 
injects  the  sohition  of  soap  and  water.  When  half  a  pint  has  been 
introduced,  the  supply  is  cut  off  and  the  evacuation  tube  opened. 
If  the  contents  of  the  rectum  do  not  flow  out,  the  bulb  is  pressed 
and  relaxed  after  the  manner  of  using  a  Davidson's  syringe.  This 
process  is  repeated  until  the  bowels  are  freely  evacuated.  The  bow- 
els were  moved  in  this  way  until  the  twelfth  day  (the  sutures  were 
removed  on  the  ninth) ;  after  that  the  bowels  were  moved  daily  by 
the  senna  and  salts.  At  the  end  of  three  weeks  the  restoration  of 
the  muscle  was  as  perfect  as  could  be,  and  the  patient  was  dismissed 
with  complete  retaining  powder. 

This  case  illustrates  the  danger  there  is  of  the  ends  of  the  sphinc- 
ter muscle  being  torn  apart  when  the  bowels  are  moved.  A  skilled 
nurse,  well  used  to  the  management  of  such  cases,  can  do  much  to 
avoid  this  imfortunate  accident,  and  yet  when  all  care  is  exercised  it 
will  often  happen.  In  order  to  avoid  this,  several  ways  have  been 
tried.  Keeping  the  bowels  confined  for  ten  or  twelve  days  was  the 
fashion  for  a  long  time.  More  recently  some  operators  have  kept 
the  bowels  free  by  laxatives  that  rendered  the  contents  fluid  and  pro- 
cured an  evacuation  every  day  after  the  second  day  from  the  opera- 
tion. I  have  tried  both,  and  now  prefer  the  reflux-catheter  evacuator 
when  a  nurse  can  be  obtained  who  knows  how  to  use  it.  When 
this  is  not  possible,  I  prefer  to  keep  the  contents  of  the  bowels  solu- 
ble and  to  move  them  every  second  day — beginning  on  the  third  day 
after  the  operation. 

When  union  is  obtained,  excepting  of  the  sphincter  muscle,  as  in 
the  case  just  related,  and  a  second  operation  is  performed,  some  op- 
erators prefer  to  begin  de  novo,  dividing  the  united  portion  and  then 
proceeding  as  in  the  primary  operation.  I  much  prefer  to  keep  all 
that  has  been  gained  and  to  restore  the  sphincter  in  the  way  already 
described.  I  was  first  induced  to  adopt  this  method  in  a  case  that 
had  been  twice  operated  upon  before  it  came  to  me  with  the  result 
of  restoring  all  but  the  sphincter.  So  much  tissue  had  been  removed 
that  I  dared  not  risk  a  possible  complete  failure,  hence  I  attempted 
to  restore  the  sphincter  in  the  way  just  described,  and  with  success. 
My  second  case  of  this  kind  was  one  in  which  complete  laceration 
occurred  during  labor ;  primary  union,  without  sutures,  of  the  peri- 
neal body  took  place,  but  not  of  the  sphincter.  Since  then  I  have 
repeatedly  operated  successfully  in  such  cases  of  partial  failure  in  my 
own  practice  and  that  of  others, 

Treatment  of  the  Transverse  or  Internal  Lacerations. — Dr.  Emmet 
was  the  first  surgeon  to  devise  an   operation  for  the  relief  of  this 


164 


DISEASES   OF  WOMEN. 


injury.  I  had  lono;  observed  and  comprehended  the  transverse 
or  internal  injury,  but  never  conceived  of  any  method  of  remedying 
it  until  I  heard  from  Emmet.  I  found  that  by  supporting  the 
pelvic  lioor  dur- 
ing convalescence 
from  confine- 
ment, in  C9^ses  in 
which  this  inju- 
ry had  occurred, 
some  effort  to  re- 
pair the  injury 
by  natural  heal- 
ing processes  was 
made,  and  quite 
successfully  in 
some,  but  when 
the  injury  per- 
sisted and  the  usual  pathological  changes  developed  in  consequence 
of  this  injury,  no  operation  that  I  had  ever  tried  was  really  of  any 
service  in  restoring  the  structures.  As  soon  as  Dr.  Emmet  gave  to 
the  profession  his  discoveries  in  this  department  I  saw  the  great 
importance  of  his  valuable  contribution  to  this  branch  of  pelvic  sur- 
gery, and  I  began  at  once  to  practice  the  operation  as  best  I  could. 
I  have  found  that  it  meets  every  indication  most  fully  in  cases  of 
transverse  internal  laceration  in  which  the  pelvic  floor  itself  is  in 
perfect  condition.  The  operation  is  not  adequate  when  the  pelvic 
floor  has  sustained  a  subcutaneous  laceration,  or  when  atrophy  has 
occurred  in  the  median  line  from  stretching — a  common  complica- 
tion of  the  transverse  laceration  if  permitted  to  exist  for  an}'  great 
length  of  time.  In  these  conditions  I  find  it  necessary  to  modify 
Dr.  Emmet's  method  of  operating  in  order  to  oljtain  the  results 
required.  Moreover,  I  have  obtained  better  results  by  treating  the 
so-called  rectocele  somewhat  differently  from  the  way  in  which  it  is 
treated  by  Dr.  Emmet. 

In  Emmet's  operation  we  are  directed  to  vivifj'  the  tissues  up  to 
the  most  prominent  part  of  the  rectocele,  and  then  continue  the 
vivifying  upward  in  the  vagina  on  cither  side  beyond  the  uppermost 
portion  of  the  rectocele  and  as  far  as  the  laceration  of  the  levator- 
ani  muscle  extends.  No  tissue  is  removed  in  the  median  line  from 
the  posterior  commissure  down  toward  the  anus.  So  far  as  the  lat- 
eral denudation  in  the  vagina  and  suturing  are  concerned,  I  follow 
the   Emmet   method.     In   the   median   line  I  remove  only  tissue 


INJURIES   TO   THE   PELVIC   FLOOR. 


165 


enough  to  liberate  the  vaginal  wall  from  the  pelvic  floor  and  then 
reflect  it  upward  and  backward.  I  then  divide  the  tissues  in  the 
median  line  down  to  the  sphincter-ani  muscle,  or  down  to  where  I 
And  muscular  tissue  and  fascia ;  in  other  words,  prodiice  by  incision 
a  complete  median  laceration.  The  angles  in  the  vagina  are  then 
brought  together  by  the  sutures  down  to  the  muscular  tissue  of  the 
pelvic  floor— that  is,  down  to  the  bulbo-cavernosus  and  the  ends  of 
the  transversus  muscle  on  either  side.  The  muscle,  fascia,  and 
integument  are  then  closed  by  sutures  from  below  upward  ;  the  en- 
larged vessels  and  cellular  tissue  are  crowded  backward  toward 
the  rectum  and  the  vaginal  wall  united  to  the  floor  of  the  pelvis 
with  the  sutures,  which  bring  together  the  lateral  edges  of  the  pelvic 
tloor. 

By  this  procedure  the  muscles  and  fascia  in  the  median  line  are 
restored ;  the  muscular  wall  of  the  vagina  is  attached  to  the  pelvic 
floor  as  far  back  as  the  rectum  and  upward  to  the  posterior  commis- 
sure. By  this  method  the  so-called  rectocele  is  completely  disposed 
of  and  the  posterior  wall  is  held  downward  and  backward  in  its 
normal  position  ; 
in    other    words,  ^, 

made  to  resume 
its  normal  rela- 
tions to  the  pelvic 
floor  (see  Fig.  60). 

In  this  way 
the  essential  req- 
uisites are  ob- 
tained :  first,  the 
central  part  of  the 
floor  is  restored  ; 
the  so-called  rec- 
tocele is  disposed 
of  without  loss  of 
vaginal  tissue;  the 
normal  relations  of  the  vagina  and  pelvic  floor  are  established,  and 
the  overdistended  veins  receive  more  support  than  can  be  offered 
by  any  other  operation  known  to  me.  The  veins  should  not  be 
wounded  if  this  can  possibly  be  avoided,  either  while  vivifying  the 
tissues  or  introducing  sutures.  If  by  chance  a  vein  is  wounded  it 
should  be  exsected,  or  the  opening  closed  with  a  ligature  ;  this  guards 
the  patient  from  phlebitis  and  extravasation.  The  veins  can  usually 
be  avoided  while  suturing  by  separating  them  from  the  vaginal  wall 


166  DISEASES   OF   WOMEN. 

and  pressing  them  downward  and  backward  while  passing  the  needle. 
In  regard  to  the  arteries  which  usually  lie  just  beneath  the  vaginal 
wall,  no  harm  comes  from  dividing  them  if  they  are  ligated  or 
caught  in  the  sutures ;  in  fact,  the  closure  of  the  arteries  may  be 
beneficial  in  lessening  the  blood  supply  during  convalescence,  thereby 
allowing  the  veins  to  regain  their  original  caliber. 

In  addition  to  the  ordinary  dressing,  a  compress  and  bandage 
should  be  applied  to  support  the  pelvic  floor  and  prevent  traction 
being  made  upon  the  internal  sutures  while  the  union  is  taking 
place. 

I  must  i«emark  that  I  use  the  prepai-ed  silk  suture  in  this  as  in 
all  operations,  and  hei-e  its  advantages  are  very  pronounced.  Emmet 
uses  silver  wire,  and  any  one  who  has  seen  the  irritation  that  comes 
from  a  number  of  such  sutures  in  the  lower  portion  of  the  vagina 
and  the  difficulty  of  removing  them  needs  no  argument  to  convince 
him  of  the  superiority  of  silk  sutures. 


CHAPTER  VIII. 

FISTULA    IX    ANO    AND   COCCYODVNIA. 

FISTULA  IN"  ANO. 

Fistula  m  ano  in  women  differs  in  no  wise  from  the  same  affec- 
tion in  men,  so  far  as  its  pathology,  symptoms,  and  physical  signs  are 
concerned  ;  and,  as  these  are  fully  described  in  treatises  on  surgery,  I 
shall  treat  of  them  here  only  incidentally.  But  the  treatment  of  fistula 
in  women  has  some  important  peculiarities  connected  with  it,  and  I 
propose,  therefore,  in  this  chapter  to  deal  with  the  subject  of  treat- 
ment alone,  giving  special  attention  to  those  points  of  difference  as 
I  have  observed  them  in  the  two  sexes. 

Having  had  several  very  unsatisfactory  results  in  treating  fistula 
in  ano  according  to  the  usual  methods  of  surgery,  I  determined  some 
years  ago  to  seek  other  means  better  adapted  to  the  relief  of  that 
■affection  of  the  rectum.  The  history  of  my  own  failures,  and  those 
which  I  have  seen  after  treatment  by  other  surgeons,  may  be  the 
best  introduction  to  what  I  have  to  say  on  this  subject.  My  first 
■case,  treated  in  hospital,  was  a  dissipated  woman,  who  did  not  know 
her  age,  but  appeared  to  be  about  sixty.  She  had  a  very  severe 
purulent  vaginitis,  presumed  to  be  a  neglected  gonorrhoea,  and  also 
a  fistulous  opening  extending  from  the  side  of  the  perinseum,  about 
three  quarters  of  an  inch  from  the  mesial  line,  into  the  rectum  above 
the  sphincter  muscle.  When  the  vaginitis  was  relieved,  I  treated 
the  fistula  by  laying  it  open  in  the  usual  way  and  placing  some  lint 
in  the  wound  so  as  to  make  it  heal  by  granulation  from  the  bottom ; 
in  this  I  was  disappointed.  The  divided  surfaces  slowly  healed  over, 
but  did  not  unite  by  intervening  granulations  or  by  new  tissue. 
The  result  was  that  the  divided  ends  of  the  sphincter  muscle  were 
never  united,  and  the  patient  lost  the  retaining  power  of  her  rectum. 
During  the  healing  process  applications  were  made  to  the  parts,  in 
the  hope  of  exciting  proliferations  to  fill  in  the  space,  but  without 
avail.  The  patient,  a  disgusting  creature  to  begin  with,  became 
much  worse  after  the  operation. 

167 


168  DISEASES  OP  WOMEN. 

While  I  was  thinking  of  some  way  to  restore  her  sphincter,  she 
was  granted  leave  of  absence  from  the  hospital  one  afternoon,  and, 
promptly  getting  drunk,  was  arrested  and  sent  to  jail  next  morning 
by  the  police  justice,  who  remembered  her  of  old.  What  her  sub- 
sequent history  was  I  do  not  know,  but  I  do  know  that  I  felt  relieved 
when  I  heard  of  the  disposition  made  of  her  by  the  judge. 

The  next  case  of  fistula  occurred  in  private  practice ;  it  was  that 
of  a  young  lady  who  broke  down  from  over-taxation  and  dysmenor- 
rhoiu.  She  had  a  pelvic  abscess  and  finally  a  fistula,  which  I  was 
called  u|)on  to  treat  after  her  physician  had  partially  restored  her 
health.  The  external  opening  of  the  fistula  was  situated  in  the  an- 
terior and  lateral  portion  of  the  perineeum.  Owing  to  my  experience 
with  my  hospital  patient  I  was  un^\'illing  to  operate  in  the  same 
way,  but  gladly  decided  to  employ  the  elastic  ligature,  strongly  rec- 
ommended at  that  time  in  the  ti-eatment  of  fistula.  Accordingly,  I 
passed  the  ligature  through  the  canal,  and,  bringing  the  end  out 
through  the  anus,  tied  it  rather  tightly.  Considerable  pain,  which 
caused  my  patient  great  suffering,  followed,  and  lighted  up  many  of 
the  old  nervous  symptoms  from  which  she  had  just  recovered.  The 
ligature  cut  its  way  outward  rather  too  rapidly,  perhaps,  and  in  six 
days  all  the  tissues  were  divided  except  a  very  small  portion  of  the 
skin,  which  I  snipped  with  scissors.  The  parts  healed  over,  but  the 
ends  of  the  sphincter  muscle  did  not  unite.  In  fact,  the  result  was 
al)Out  the  same  as  in  my  hospital  case.  For  a  long  time  the  retain- 
ing power  of  the  rectum  was  completely  lost.  Two  years  after  the 
operation  I  examined  her,  and  found  that  the  contraction  of  the  scar 
tissue  had  brought  the  ends  of  the  muscle  nearer  together,  but  still 
the  function  of  the  sphincter  was  imperfect.  The  patient  was  un- 
able to  retain  fluid  foeces  or  gas,  although  when  slightly  constipated 
she  experienced  very  little  trouble. 

Two  other  cases  have  come  under  my  observation,  in  which  the 
conditions  presented  were  very  much  like  those  described  in  my  own 
cases. 

The  first  one  was  a  lady,  thirty -two  years  of  age,  married  for  ten 
years,  and  sterile.  For  three  years  she  had  suffered  from  a  painful 
growth  at  the  meatus  urinarius  ;  this  gave  rise  to  so  great  tenderness 
as  to  prevent  coitus  and  to  cause  distress  during  micturition.  The 
tumor  was  removed  and  the  parts  healed  well  after  the  operation, 
but  still  she  had  symj^toms  of  vaginismus  which  compelled  her  to 
return  for  further  treatment.  A  careful  examination  revealed  the 
following  condition  :  The  perinseum  was  shorter  than  normal,  and 
was  drawn  upward  Ijy  the  action  of  the  si)hincter-vagin8e  muscle 


FISTULA  IN  ANO  AND  COCCYODYNIA.  169 

until  it  nearly  closed  the  introitus  vaginne.  The  rectum  appeared  to 
be  also  drawn  forward,  so  that  the  distance  from  the  posterior  wall 
of  the  rectum  to  the  meatus  urinarius  was  altogether  shorter  than  is 
usually  found.  A  scar  was  formed  on  the  right  margin  of  the  anus. 
The  function  of  the  sphincter  ani  was  impaired.  Upon  inquiry,  I 
learned  that  seven  years  before  she  had  been  operated  on  for  fistula, 
and  had  never  since  had  complete  control  of  the  rectum. 

The  other  case  referred  to  so  closely  resembled  in  history  those 
just  given  that  it  need  not  be  related  in  full.  The  only  point  of 
difference  was  that  this  patient  sought  advice  regarding  her  want  of 
control  of  the  rectum.  It  will  be  observed  that  in  all  four  of  these 
cases  the  fistulse  were  situated  either  upon  the  anterior  or  lateral 
margins  of  the  anus.  A  question  here  arises,  whether  the  operation 
for  fistula  situated  more  toward  the  posterior  margin  of  the  rectum 
would  terminate  in  the  same  unfavorable  way.  This  I  can  not  an- 
swer, as  I  have  never  seen  a  case ;  I  can  not,  however,  see  any  reason 
why  it  should  not  do  so.  I  am  not  disposed  to  believe  that  the  re- 
sults obtained  in  the  operation  for  fistula  in  ano  are  always  so  unfort- 
unate as  in  the  cases  recorded  here.  If  that  had  proved  to  be  the 
case,  the  attention  of  surgeons  would  have  been  given  to  the  subject 
long  ago. 

That  the  power  of  the  sphincter-ani  muscle  is  lost  in  a  large 
number  of  cases  after  the  operation  is,  I  believe,  a  fact.  I  might  go 
further  than  this  and  say  that,  in  all  cases  in  which  the  fistula  is  lo- 
cated completely  outside  of  the  muscle,  and  it  is  therefore  necessary 
to  divide  the  sphincter  in  operating,  there  is  great  danger  that  it  will 
not  be  fully  restored.  The  divided  muscle  retracts,  and  the  space 
between  its  ends  is  filled  in  very  slowly  with  new  tissue;  as  a  result, 
there  is  usually  a  large  amount  of  scar  tissue  necessary  to  connect 
the  two  ends.  This  must  impair  its  functions,  if  it  does  not  entirely 
destroy  it. 

In  a  healthy  subject  in  whom  the  termination  of  the  fistula  does 
not  extend  far  outward,  and  the  induration  of  the  tissues  around  the 
canal  is  not  extensive,  the  healing  process  may  go  on  rapidly,  thus 
connecting  the  ends  of  the  muscle  by  means  of  intervening  new  tissue. 
Under  such  circumstances,  the  function  of  the  muscle  may  be  re- 
tained ;  on  the  other  hand,  if  the  fistula  extends  from  high  up  in  the 
rectum  to  a  point  some  distance  outside  of  the  muscle,  the  operation 
is  almost  sure  to  be  a  failure.  Of  course,  the  greater  the  amount  of 
tissue  between  the  rectum  and  the  fistula,  the  farther  will  the  ends 
of  the  muscle  be  separated  by  retraction,  and  the  longer  will  the 
parts  be  m  healing.     In  such  cases  the  function  of  the  sphincter  is 


170  DISEASES  OF  WOMEN. 

very  liable  to  be  impaired.  "When  tbe  fistula  is  located  beneath  the 
mucous  membrane  only,  then  a  perfect  result  can  always  be  obtained. 
Mr.  John  Gray  ("Lancet,"  December  11,  1880)  states  that  operative 
treatment  should  be  deferred  until  the  walls  of  the  abscess,  as  well 
as  the  consequent  fistulous  tract,  have  assumed  a  condition  of  health 
and  a  disposition  to  take  on  a  healing  process.  This  is  certainly  a 
good  rule  in  surgery,  because  it  secures,  as  far  as  possible,  the  con- 
dition necessary  to  prevent  fecal  incontinence.  In  order  to  avoid 
such  unfavorable  results,  it  was  evidently  necessary  to  operate  with- 
out dividing  the  sphincter  muscle,  or,  if  that  were  impracticable,  to 
secure  union  of  the  divided  ends  of  the  muscle  with  the  least  possi- 
ble quantity  of  intervening  new  tissue. 

In  the  hope  of  curing  the  fistula  without  dividing  the  sphincter, 
the  following  method  was  adopted :  An  incision  was  made  through 
the  skin  and  lower  part  of  the  sinus  large  enough  to  admit  two  fin- 
gers below  and  one  at  the  upper  end  of  the  wound.  The  edges  of 
the  wound  were  held  apart  with  retractors^  and  the  opening  in  the 
rectum  was  found  and  brought  into  view  by  passing  the  finger  into 
the  rectum  and  everting  the  rectal  wall  through  the  wound.  The 
edges  of  the  opening  in  the  rectal  wall  were  then  pared  with  the 
scissors,  and  two  or  more  catgut  sutures  were  introduced  and  tied. 
The  external  edges  of  the  wound  were  kept  apart  by  a  pledget  of 
carbolized  lint,  which  was  changed  every  day  until  the  wound  healed. 
The  idea  was  to  first  convert  a  complete  fistula  into  a  blind  external 
one,  and  then  finish  the  cure  by  compelling  the  external  sinus  to  heal 
from  below  outward.  To  prevent  any  strain  upon  the  sutures  by 
distention  of  the  rectum,  I  paralyzed  the  sphincter  by  overdistention, 
and  kept  the  bowels  free  by  saline  laxatives.  Of  two  cases  treated 
in  this  way  one  was  a  success  and  the  other  only  partially  so,  as 
the  opening  into  the  rectum  closed,  but  a  blind  external  fistula  re- 
mained. 

Regarding  this  method  of  treating  fistula,  I  can  only  say  that  the 
danger  of  losing  the  sphincter  muscle  is  avoided,  which  is  very  im- 
portant, but  there  are  objections  to  it.  The  operation  is  diflicult  to 
perform — at  least  the  closing  of  the  opening  in  the  rectum  with  sut- 
ures is  not  easy — and,  then,  my  impression  is  that  it  will  fail  to  cure 
some  cases. 

While  thinking  of  some  other  uK'thod  of  treatment  more  satis- 
factory than  that  given  above,  I  noticed  a  suggestion  in  the  "■  Chicago 
Medical  Review,"  by  Dr.  Dudley,  to  lay  open  the  fistula,  trim  oft 
the  indurated  tissues  along  its  track,  and  treat  as  a  lacerated  perinn?um, 
with  sutures.     It  occurred  to  me  that  this  method  was  deserving  of 


FISTULA  IN  ANO   AND  COCCYODYNIA. 


171 


a  trial,  and  I  determined  to  put  it  to  the  test  of  practice  as  soon  as  I 
could  get  an  opportunity.  It  was,  of  course,  impossible  to  tell  what 
the  results  would  be,  but  I  thought  that  it  promised  as  much  as  the 
methods  which  I  had  used.  Such  an  opportunity  presented  itself  to 
me,  and  the  result  will  he  seen  in  the  following  history : 

Fistula  in  Ano  successfully  treated  by  the  New  Method. — The  pa- 
tient was  a  married  lady,  who  had  anteflexion  of  the  uterus,  which 
caused  sterility.  On  two  occasions  she  had  dysentery,  which  left  a 
tender  condition  of  the  rectum  and  haemorrhoids.  While  under 
treatment  for  the  flexion  of  the  uterus,  she  had  an  abscess  on  the 
right  side  of  the  anus,  which  terminated  in  the  formation  of  a  com- 
plete fistula.  The 
external  opening 
was  about  an  inch 
from  the  anus  on 
tlie  right  side,  and 
the  internal  open- 
ing was  immedi- 
ately above  the 
sphincter-ani  mus- 
cle. 

There  was  the 
usual  exudation 
around  the  fistu- 
lous tract,  but  it 
was  not  so  exten- 
siye  as  in  many  of 
these  cases.  The 
rectum  hanng 
been  thoroughly 
washed  out  with 
disinfectants,  after 
a  free  evacuation 
of  the  bowels,  a 
bivalve  rectal  sj^ec- 
ulum  was  intro- 
duced and  the  fis- 
tula laid  open.  The 
scar  tissue  was  care- 
fully dissected  out, 
and  special  care  was  taken  to  vivify  the  mucous  membrane  around 
the  upper  opening  of  the  fistula.     The  ends  of  the  sphincter  muscle 


Fig.  90. — The  operation  for  fistula;  the  tract  laid  open  and  the 
sutures  in  place,     a,  anus  ;  f,  outer  end  of  fistula. 


172  DISEASES  OF  WOMEN. 

retracted,  so  that  it  was  necessary  to  remove  a  considerable  portion 
of  the  mucous  membrane  and  celhilar  tissue  in  order  to  expose  the 
ends  of  the  muscle  in  the  edges  of  the  wound.  Fine  silk  sutures 
were  then  introduced  into  the  mucous  membrane  of  the  rectum,  the 
lower  ones  being  made  to  include  the  sphincter-ani  muscle. 

Deep  sutures  were  then  introduced  from  the  outside  upward  in 
the  same  manner  as  in  the  operation  for  restoring  the  perinseum. 
Fig.  90  shows  the  sutures  in  place.  The  deep  sutures  were  tied  first. 
and  the  slight  traction  upon  them  drew  the  tissues  downward  and 
shortened  the  length  of  the  wound  very  much.  This  brought  the 
sutures  in  the  mucous  membrane  very  near  together.  I  should  have 
stated  that  before  the  fistula  was  laid  open  the  sphincter-ani  muscle 
was  stretched  until  paralyzed ;  this  prevented  any  tension  upon  the 
sutures  for  the  first  few  days. 

The  bowels  were  moved  daily,  and  after  each  evacuation  the  rec- 
tum was  washed  out  with  carbolized  water.  There  was  a  little  sup- 
puration in  the  track  of  one  deep  suture,  but  union  was  complete  in 
ten  days.  The  deep  sutures  were  removed  on  the  ninth  day,  and 
the  sutures  in  the  mucous  membrane  were  removed  at  the  end  of 
two  weeks. 

The  recovery  was  perfect,  the  function  of  the  sphincter  muscle 
being  fully  restored. 

COCCYODYNIA. 

This  affection  was  first  described  as  a  neuralgia  of  the  coccyx  by 
Dr.  Xott  in  the  "j^orth  American  Medical  Journal,"  May,  18-i4, 
but  it  attracted  little  attention  until  1861,  when  Sir  James  Y.  Simp- 
son revived  the  subject  and  gave  it  the  name  which  it  now  bears. 

Pathology. — Pain  upon  moving  the  coccyx  and  contracting  the 
muscles  attached  to  it  is  the  chief  characteristic  of  this  disorder. 
The  morbid  conditions  found  are  variable.  Fracture  and  dislocation 
of  long  standing  and  caries  of  the  coccyx  have  been  discovered  in 
some  cases ;  in  others,  no  appreciable  lesions  can  be  detected.  It  is 
presumed  that,  in  the  absence  of  structural  changes  of  the  bone  and 
muscles,  the  pain  may  be  due  to  rheumatism  of  the  tendons  of  the 
muscles  or  neuralgia  of  the  nerves  distributed  to  them. 

Sym])tomatolo()ij . — There  is  little  or  no  suffering  while  the  pa- 
tient is  at  rest,  but  upon  rising,  sitting  down,  or  evacuating  the  bow- 
els, pain  over  the  coccyx  is  experienced.  Sitting  is  painful  in  some 
cases,  owing  to  pressure  upon  the  bone.  Any  sudden  movement  is 
attended  with  suffering.  Some  patients  are  unable  to  rise  from  a 
low  seat  without  assistance. 


FISTULA  IN  ANO   AND  COCCYODYNIA.  I73 

Physical  Signs. — Tenderness  uj)on  pressing  and  moving  the  coc- 
cyx is  tlie  chief  diagnostic  sign.  Painful  hgemorrhoids.  lissure  of 
the  anus,  and  spasm  of  the  adjacent  muscles  caused  by  ascarides  in 
the  rectum,  may  be  mistaken  for  this  affection,  but  they  can  be  ex- 
cluded by  physical  examination. 

Prognosis. — Some  cases  of  coccyodynia  are  slight,  and  wear  away 
in  time  without  special  treatment ;  but,  though  the  disease  may  not 
perceptibly  injure  the  general  health  of  the  patient,  it  is  often  of  such 
long  duration,  and  occasions  so  much  suffering  and  inconvenience, 
that  it  is  necessary  to  resort  to  surgical  means  for  relief. 

Causation. — Women  who  have  borne  children  are  the  most  fre- 
quent, though  not  the  only,  sufferers  from  this  disorder.  Injuries 
sustained  in  parturition,  or  blows  upon  the  coccyx,  exposure  to  cold, 
and  diseases  of  the  ovaries  and  uterus,  are  its  chief  causes. 

Treatment. — The  surgical  methods  of  treatment  are  those  prac- 
ticed by  Prof.  Simpson  and  Dr.  Nott.  I^either  of  them  is  danger- 
ous, and  one  or  the  other  is  certain  to  give  satisfactory  results. 

By  Prof.  Simpson's  method  an  ordinary  tenotomy -knife  is  in- 
serted at  the  lowest  point  of  the  coccyx,  and  passed  flatwise  between 
the  skin  and  celkilar  tissue  till  its  point  reaches  the  junction  of  the 
sacrum  and  coccyx.  Then  the  knife  is  turned  and  withdrawn,  mak- 
ing a  subcutaneous  incision  which  entirely  severs  the  muscles  over 
one  side  of  the  coccyx.  The  same  operation  is  repeated  on  the  other 
side.  No  haemorrhage  is  to  be  feared  in  subcutaneous  operations 
unless  some  large  vessel  should  be  cut. 

An  easier  operation,  and  one  more  likely  to  effect  a  cure,  is 
performed  by  exposing  the  coccyx  through  an  external  incision, 
raising  the  extremity  of  the  bone,  and  severing  the  muscles  with  a 
pair  of  scissors.  The  subcutaneous  operation,  always  difficult,  is 
nearly  impossible  where  the  bone  is  covered  with  much  adipose 
tissue. 

Should  the  bone  itself  be  diseased,  section  of  the  muscles  would 
not  effect  a  cure.  In  such  cases  the  coccyx  must  be  laid  bare,  dis- 
articulated by  the  knife,  and  amputated,  according  to  the  method  of 
Dr.  Xott. 

The  complete  removal  of  the  coccyx  is  the  ovlLj  method  which 
has  proved  satisfactory  in  my  practice.  jSTott's  method  of  023erating 
is  to  expose  the  coccyx,  detach  the  muscles,  and  then  take  it  oft'  from 
the  sacrum  with  the  bone-forceps.  In  this  operation  there  is  danger 
of  injuring  the  sacrum,  and  causing  a  subsequent  necrosis.  I  there- 
fore prefer  to  disarticulate  with  the  knife  or  scissors,  cutting  through 
the  cartilage. 


174  DISEASES  OF  WOMEN. 

While  all  mj  operations  Lave  been  finally  successful,  I  have 
several  times  seen  great  suffering  and  slow  healing  follow. 

The  subjoined  cases  will  illustrate  the  pain  and  suffering  which 
may  follow  the  operation. 

ILLUSTRATIVE    CASES. 

Removal  of  the  Coccyx  and  Lower  Segment  of  the  Sacrum ;  Recov- 
ery.— A  married  lady,  twenty- four  years  of  age,  was  thrown  from  a 
carriage  and  injured  by  falling  upon  her  back  and  side,  bruising  the 
lower  end  of  the  spine,  and  having  what  was  supposed  to  be  a  fract- 
ure of  the  neck  of  the  femur.  After  recovering  from  the  imme- 
diate effect  of  the  accident,  she  suffered  from  severe  pain  in  tlie 
coccyx.  At  first  the  pain  in  that  region  was  almost  continuous,  and 
greatly  aggravated  by  locomotion.  For  about  six  months  from  the 
time  of  her  accident  she  was  tolerably  comfortable  while  resting,  but 
suffered  greatly  when  moving  around,  especially  upon  rising  from  a 
chair  or  sitting  down  or  turning  in  bed.  She  also  had  severe  at- 
tacks of  sick  headache  and  pains  in  the  back  of  the  neck. 

On  physical  exploration  it  was  found  that  the  coccyx  and  lowest 
segment  of  the  sacrum  projected  inward  at  nearly  right  angles  to 
the  axis  of  the  sacrum.  In  this  dislocation  the  coccyx  was  firmly 
fixed.  The  dislocation  and  the  tenderness  gave  rise  to  violent  pain 
on  defecation. 

The  Ojieration  consisted  in  removing  the  coccyx  and  the  lowest 
segment  of  the  sacrum.  A  free  incision  was  made  and  all  the  mus- 
cles and  attached  ligaments  were  separated,  and  then  the  part  to  be 
removed  was  carefully  disarticulated  without  any  injury  to  the  bone. 
The  operation  was  done  with  all  antiseptic  precautions,  all  hjeraor- 
rhage  was  controlled,  and  the  edges  of  the  wound  were  brought  to- 
gether with  sutures,  and  dressed  with  absorbent  cotton. 

On  recovering  from  the  anaesthetic  she  complained  of  the  most 
agonizing  pain  in  the  lower  liaK  of  the  back,  pelvis,  and  limbs. 
This  pain  continued  for  the  first  three  days,  and  was  only  partially 
controlled  by  large  hypodermics  of  Magendie's  solution,  ten  minims, 
every  two  to  four  hours. 

An  effort  was  made  to  relieve  the  pain  with  opium  given  by  the 
mouth,  but,  although  seven  grains  were  given  in  twelve  hours,  it 
was  necessary  to  repeat  the  hypodermics  to  give  her  relief.  During 
all  this  time  of  suffering  the  wound  appeared  to  be  healing,  there 
was  no  undue  inflannnation,  and  no  suppuration.  Five  days  after 
the  operation  the  pain  was  more  easily  controlled  by  the  morphine, 
and  then  the  sutures  were  removed,  and  the  pain  from  this  time  on- 


FISTULA  IN   ANO  AND   COCCYODYNIA.  I75 

ward  diminished  quite  rapidly.  At  this  time  the  wound  appeared 
to  be  completely  healed,  but  a  portion  of  the  cicatrix  broke  down, 
and  subsequently  healed  by  granulation.  From  this  time  on  her 
progress  was  entirely  satisfactory,  the  pain  subsided  in  the  neighbor- 
hood of  the  wound  and  spinal  column,  and  she  was  entirely  relieved 
from  her  sick  headaches. 

Removal  of  Coccyx ;  Extreme  Pain  after  Operation ;  Delayed  Heal- 
ing of  the  Wound ;  Final  Recovery. — This  was  a  married  lady  mIio 
had  one  child  about  eight  years  old.  She  had  suffered  from  pelvic 
cellulitis  following  miscarriage,  so  that  her  health  was  very  m-uch 
impaired.  She  fell  down-stairs  and  injured  her  coccyx  about  two 
years  before  she  came  under  my  observation. 

She  recovered  completely  from  her  pelvic  cellulitis.  She  de- 
veloped all  the  symptoms  and  physical  signs  of  coccyodynia.  The 
operation  was  performed  in  the  usual  way,  and  every  care  taken  to 
secure  a  good  result.  After  ligating  the  small  vessels,  which  bled 
rather  freely,  there  was  a  little  serous  oozing,  so,  before  closing  the 
wound  with  sutures,  I  introduced  a  few  strands  of  catgut  for  drain- 
age, and  dressed  the  wound  with  borated  cotton. 

From  the  time  of  the  operation  she  had  a  great  deal  of  pain  and 
tenderness  in  the  region  of  the  wound ;  this  pain  and  tenderness  in- 
creased until  it  was  necessary  to  give  anodynes  liberally  to  relieve 
them.  After  about  five  days  the  violent  pain  subsided,  but  the 
wound  was  still  exceedingly  sensitive;  the  drainage-threads  were  re- 
moved about  the  second  day,  and  the  sutures  at  the  end  of  one  week. 
The  union  was  complete,  except  a  sinus  in  the  center  which  ex- 
tended downward  the  depth  of  the  original  wound.  This  promptly 
closed  up  after  a  few  more  weeks,  but  there  was  still  great  tender- 
ness remaining  there.  She  returned  to  her  home  thirty  daj^s  after 
the  operation,  with  the  wound  apparently  healed  but  still  tender. 
She  was  free  from  her  occipital  headaches  and  from  most  of  her  dis- 
tressing symptoms. 

Some  time  after  her  return  home  the  wound  reopened,  and,  al- 
though every  care  was  taken  of  the  case  by  the  physician  in  charge, 
it  was  nearly  six  months  before  it  healed  entirely.  Through  all  this 
time  she  was  free  from  the  suffering  which  she  had  before  the  opera- 
tion, but  the  wound  was  still  tender.  Since  then  she  has  been  per- 
fectly well. 

Fissure  in  Ano. — This  patient  was  suffering  from  a  small  fissure  or 
ulcer  in  one  of  the  folds  of  the  mucous  membrane  within  the  grasp 
of  the  sphincter-ani  muscle.  The  fissure  was  exposed  with  the  aid  of 
the  rectal  speculum.    The  cautery  was  placed  at  the  upper  end  of  the 


176  DISEASES   OF  WOMEN. 

fissure  and  heated,  and  then  drawn  downward  through  the  surface, 
and  the  diseased  surface  was  completely  but  very  superficially  cau- 
terized. The  cautery  in  these  cases  should  be  very  lightly  applied 
to  prevent  deep  destruction  of  the  tissues,  which  would  cause  a 
slough  and  retard  healing.  In  many  cases,  when  the  ulceration  is 
very  superficial,  I  do  not  touch  the  parts  with  the  cautery  at  all ; 
only  hold  it  near  enough  to  produce  the  efliect  desired  by  the  radiated 
lieat. 


CHAPTER   IX. 


INFLAMMATORY    AFFECTIONS    OF    THE   UTERUS. 


ANATOMY   OF  THE   UTERUS. 


Before  taking  up  the  various  forms  of  endometritis,  a  few  words 
regarding  the  anatomy  and  physiology  of  the  uterus  will  aid  in  mak- 
ing clear  what  follows  with  reference  to  the  pathology  and  physical 
signs  of  this  variety  of  uterine  disease.  The  uterus  is  a  triangular 
body  with  its  apex  below  when  in  its  normal  position  in  the  pelvis. 
It  varies  in  size  in  different  persons,  and  is  somewhat  larger  in  those 
who  have  borne  children  than  in  virgins.  Its  entire  length  is  about 
three  inches ;  the  width  from  the  entrance  of  one  Fallopian  tube 
to  the  other,  that 
is,  the  base  of  the 
triangle,  is  about 
two  inches  ;  and  it 
is  about  one  inch 
in  thickness.  It  is 
divided  into  the 
•fundus,  body,  and 
■cervix,  the  cervix 
being  about  as  long 
as  the  body  and 
very  nearly  as 
thick.  The  cervix 
is  divided  into  the 
intravaginal  and 
the  supravaginal 
portions,  the  form- 
er being  that  part 

which  projects  into  the  vagina,  and  the  latter  that  which  extends 
irom  above  the  vagina  to  the  body  of  the  uterus. 
13  1^^ 


Fig.  91. — Mold  of  uterine  cavity 
ill  tlie  virgin  (Guyon):  a,  os 
internum  ;  d,  os  externum. 


Fig.  92.— Mold  of  uter- 
ine cavity  in  the  multi- 
para (Guyon). 


1Y8 


DISEASES   OF   WOMEN. 


-,■1.,./,,  7„  f,,  ■.,ji^^)'!'yl^'i 


fyj';!/. 


<"-/-, 


Fig.  93. — Section  of  mucous  nieinbranc  of 
uterus  from  near  the  fundus  (Schafer) : 
a,  epithelium  of  inner  surface  ;  h,  h, 
utricular  fflands  ;  c,  connective  tissue ;  d, 
muscular  tissue. 


The  walls  of  the  uterus  are 
composed  of  three  distinct  ele- 
ments :  the  outer  covering  being 
peritoneal ;  the  middle  coat,  un- 
strijDed  muscular  liber;  and  the 
internal,  mucous  membrane. 

The  peritonaeum  covers  the 
uterus  only  partially,  but  the  mu-  ' 
cous  membrane  lines  the  entire 
cavity  of  the  body  and  cervix,  and 
is  continuous  with  the  mucoud 
membrane  of  the  vagina,  although 
differing  decidedly  in  structure. 
Reference  will  be  again  made  to 
the  relation  of  the  peritonaeum  to 
the  uterus. 

The  cavity  of  the  uterus  and 
its  mucous  membrane,  which  are 
of  special  interest  in  this  connec- 
tion, are  divided  into  the  cervical 
canal  and  its  membrane  and  the 
cavity  of  the  body  and  its  mem- 
brane. The  cavity  of  the  body  is 
triangular  and  curvilinear,  while 
the  canal  of  the  cervix  is  spindle- 
shaped.  Outlines  of  the  cavity  of 
the  canal  of  the  uterus  differ  in. 
the  parous  and  imparous  uteru& 
(Figs.  91  and  92). 

The  constricted  portion  at  the- 
junction  of  the  body  and  cervix  is 
the  OS  internum,  and  the  termina- 
tion of  the  canal  below  is  the  os 
externum.  Taking  the  cavity  of 
the  uterus  in  its  entirety  as  repre- 
senting a  triangle,  with  an  opening 
at  each  of  the  angles,  we  find  at 
the  upper  angles  the  openings  of 
the  Fallopian  tubes,  and  at  the 
lower  angle  the  os  externum. 

The  mucous  membrane  of  the 
cavity  of  the  body  is  smooth  and 


INFLAMMATORY   AFFECTIONS   OF   THE    UTERUS. 


179 


thin,  the  membrane  proper  not  being  more  than  the  one  twelfth  of 
an  inch  in  thickness.  It  is  composed  of  an  epithelial  and  basement 
layer,  and  is  firmly  united  to  the  fibrons  tissue  of  the  middle  wall 
and  connective  tissues.  It  is  covered  with  a  single  layer  of  columnar 
epitliehum,  each  epithelial  cell  having  on  its  free  surface  a  bundle 
of  cilia.  It  contains  a  number  of  glands  known  as  the  utricular 
glands.  In  a  section  of  the  mucous  membrane  these  glands  can  be 
seen  with  a  microscope  to  be  lined  with  ciliated,  columnar  epithe- 
lium, and  to  have  free  openings  on  the  surface  of  the  membrane. 
They  dip  oblique- 
ly downward,  and 
end  in  the  con- 
nective and  mus- 
cular tissues  im- 
mediately beneath 
the  membrane. 

Some  of  the 
glands  are  simple- 
others  are  bifur- 
cated at  their  low, 
er  ends  ;  some- 
times two  of  these 
glands  have  one 
opening  on  the 
free  surface. 

I  have  said 
that  the  glands 
dip  down  into  the 
muscular  libers  of 
the  middle  coat ; 
others  describe 
the  muscular  fi- 
bers as  running 
up  between  the 
glands,  which 
amounts  to  the 
same  thing.  This  arrangement  of  the  utricular  glands  in  the  mucous 
membrane  and  the  muscular  wall  of  the  uterus,  with  the  intervening 
connective  tissue,  can  be  seen  by  referring  to  Fig.  97.  The  differ- 
ences in  the  infantile  and  senile  uterus  can  be  seen  by  reference  to 
Figs.  94  and  95. 

The  mucous  membrane  lining  the  cervical  canal  is  arranged  in 


Fig.  94.- 


Transverse  section  through  middle  portionof  the  corpus 
uteri  of  an  infant  7  months  old. 


180 


DISEASES   OF   WOMEK 


an  entirely  different  manner  from  that  of  the  cavity  of  the  body. 
From  the  internal  to  the  external  os  there  are  sulci  which  divide  the 


WmiMmm^imm 


Fig,  95. — Transverse  section  throuo;h  the  middle  portion  of  the  corpus  uteri  of 
a  woman  aged  83. 

membrane  into  four  divisions  or  cohnuns.  The  membrane  between 
these  sulci  is  arranged  in  oblique  folds  or  ridges,  the  whole  making 
up  that  rugous  appearance  to  which  the  name  arhor-vitce  has  been 
given.  Fig.  96  shows  this  peculiar  arrangement  of  the  membrane. 
This  membrane  is  covered  throughout  with  ciliated  epithelium.  The 
glands  of  the  cervix,  known  as  the  glands  of  Naboth,  are  of  the 
racemose  type ;  they  open  on  the  free  surface,  dip  down,  and  divide 
into  numerous  branches,  which  extend  deep  into  the  connective  tis- 
sues. Their  openings  are  found  on  the  surface  of  the  mucous  mem- 
brane, both  in  the  elevations  and  depressions. 

The  point  at  which  the  mucous  membrane  of  the  cervical  canal 
unites  with  the  membrane  which  covers  the  vaginal  portion  of  the 
cervix  is  the  os  uteri  externum,  and  the  structure  and  ari'angement 
of  the  membrane  differ  on  the  two  sides  of  this  dividing  line.  That 
within  the  canal  is  as  I  have  described  it,  and  that  which  covers  the 
cervix  outside  of  the  os  internum  contains  none  of  the  glands  of 
Naboth,  and  has  all  the  general  characteristics  of  the  raucous  mem- 


INFLAMMATORY  AFFECTIONS   OF  THE   UTERUS. 


181 


brane  of  the  vagina.     It  consists  of  vascular  papillae  covered  "s\ith 


many  layers  of  squamous  epithelium 
pens,  the  Nabothian  glands  are 
found  upon  the  vaginal  sur- 
face of  the  cervix,  it  is  evi- 
dence that  they  have  either 
been  developed  there  or  else 
there  is  eversion  of  the  mu- 
cous membrane  of  the  cervical 
canal,  and  the  latter,  I  believe, 
is  the  true  explanation  of  their 
presence  in  most  cases. 

The  middle  or  muscular 
wall  of  the  uterus  is  com^^osed 
of  non-striped  muscular  libers 
which  appear  to  be  rudiment- 
ary in  the  unimpregnated 
uterus.  This  middle  coat  is 
divided  into  three  layers :  a 
thin  subperitoneal  one  which 
is  continued  outward  in  the 
location  of  the  uterus,  a  mid- 
dle layer,  and  an  inner  con- 
centrated and  very  abundant 
layer  which  surrounds  the  Fal- 
lopian tubes,  OS  externum,  and 
OS  internum  ;  the  inner  portion 
of  this  layer  is  less  dense  than 
the  rest  of  it,  and  there  is  more 
connective  tissue  intermingled 
with  tlie  fibro  -  muscular  tis- 
sues. It  is  into  this  layer  that 
the  uterine  and  ISTabothian 
glands  extend. 


When,  as  occasionally  hap- 


FiG.  96. — The  oblique  ramifications  of  one  of 
the  median  columns  in  the  cervical  canal  of 
a  virgin,  called  the  arbor-vitse  (9  diameters). 


FUNCTIONS    OF    THE    UTERUS. 

The  function  of  the  uterus  which  is  of  most  interest  to  the  gyne- 
cologist is  that  of  menstruation,  which  has  been  discussed  in  the 
third  chapter,  to  which  the  reader  is  referred.  It  will  be  spoken 
of  again  when  treating  of  corporeal  endometritis. 

The  function  of  the  cervix  in  relation  to  gestation  and  parturition 


182  DISEASES  OF  WOMEN. 

need  not  be  discussed  here ;  a  few  words,  however,  may  be  appro- 
priate in  regard  to  the  relation  of  the  cervix  to  impregnation. 

There  are  two  principal  theories  in  reference  to  the  function  of 
the  cervix  uteri  in  the  transmission  of  the  fecundating  element  to 
the  body  of  the  uterus.  The  one  is  that  the  cervix  dilates,  and 
that  the  secretion  of  the  glands  of  Xaboth  fills  the  canal  and  forms 
a  medium  through  which  the  spermatozoa  make  their  w^ay  upward 
by  their  own  migrating  power.  This  appears  rational  from  the  fact 
that  the  secretion  of  the  Nabothian  glands  is,  in  its  physical  proper- 
ties, similar  to  the  seminal  fluid.  The  other  theory  is,  that  the  cer- 
vix expands,  extends,  contracts  and  retracts,  producing  an  action  of 
suction,  whereby  the  spermatozoa  are  carried  up  into  the  uterus. 
AVhether  either  or  both  of  these  theories  is  correct,  there  is  no  doubt 
that  the  glands  of  Naboth  secrete  a  fluid  that  is  concerned  in  the 
great  function  of  reproduction,  and  that  derangement  of  this  func- 
tion tends  to  the  development  of  cervical  endometritis,  and  that  they 
are  subject  to  important  pathological  changes  in  that  affection. 

INTERSTITIAL   METRITIS   AND   ENDOMETRITIS. 

Interstitial  Metritis. — This  is  always  acute,  and  occurs  either  in 
the  puerperal  state  or  in  connection  with  fibromata  or  other  uterine 
neoplasms.  Puerperal  metritis  is  of  the  most  interest  to  the  obstet- 
rician, as  it  occurs  in  connection  with  parturition.  It  has  a  trau- 
matic or  septic  origin,  and  usually  involves  the  entire  uterus,  so  that 
changes  of  structure  are  found  in  the  mucous  and  muscular  coats  of 
the  organ,  constitutino;  both  interstitial  metritis  and  endometritis. 
This,  when  it  terminates  in  recovery,  tends  to  chronic  inflammation 
of  the  mucous  membi'ane.  The  process  of  involution  is  arrested 
by  this  inflannnation,  and  when  the  tissues  are  changed  by  inflam- 
matory action  the  uterus  is  not  only  larger  than  it  should  l)e,  but  is 
changed  in  structure.  This  will  be  referred  to  again  under  the 
head  of  subinvolution. 

Endometritis. — This  occurs  in  two  forms,  cervical  and  corporeal, 
both  of  which  may  be  either  acute  or  chronic.  In  the  course  of  the 
eruptive  fevers,  measles  and  scarlet  fever,  corporeal  endometritis 
sometimes  occurs  ;  this  form  is  known  as  exanthematous  endome- 
tritis. It  is  usually  an  acute  affection,  which  subsides  after  recovery 
from  the  constitutional  disease  which  causes  it ;  sometimes,  how- 
ever, when  it  occurs  in  the  young  the  uterus  is  damaged  to  such 
an  extent  as  to  arrest  its  development.  This  is,  I  am  sure,  the 
cause    of   many   cases   of    im])t'rfect   development   of   that   organ. 


INFLAMMATORY   AFFECTIONS   OF   THE   UTERUS.  183 

The  acute  form  of  the  affection  may  in  exceptional  cases  become 
chronic. 

Endometritis  due  to  gonorrhoeal  virus  will  claim  a  separate 
notice,  and  with  these  few  observations  I  shall  for  the  present  dis- 
miss all  the  varieties  except  acute  and  chronic  endometritis,  which 
will  be  discussed  in  this  chapter. 

Acute  Endometritis. — Acute  endometritis  is  exceedingly  rare  if 
puerperal,  gonorrlioeal,  and  septic  inflammations  are  excluded.  I 
am  aware  that  acute  cervical  or  corporeal  endometritis  is  described 
in  books,  and  Thomas  claims  that  the  affection  occurs  frequently  ; 
but  my  own  observations  lead  me  to  the  conclusion  that  it  does 
not  progress  beyond  the  stage  of  acute  congestion,  and  frequently 
passes  off  without  causing  the  slightest  permanent  change  of  struc- 
ture. Occasionally  the  acute  stage  subsides,  and  a  chronic  or  sub- 
acute endometritis  follows.  "When  one  follows  the  other  in  this 
way  they  stand  to  each  other  in  the  relation  of  cause  and  eflect. 
The  disease  may  affect  the  cervix  or  the  body  or  both  at  the  same 
time. 

Acute  Cervical  Endometritis  is  more  properly  an  acute  congestion, 
which  does  not  cause  any  very  marked  disturbance  either  of  the 
pelvic  organs  or  the  general  system.  The  symptoms  are  not  pro- 
nounced. Pelvic  tenesmus  of  a  slight  nature,  a  sense  of  aching  in 
the  pelvic  region,  with  or  without  backache,  is  the  evidence  ob- 
tained at  first,  and  then  leucorrhoea  soon  follows.  This  discharge 
is  usually  catarrhal  and  non-purulent.  In  some  cases  there  is  also  a 
vaginitis  and  a  vaginal  leucorrhoea  which  contains  some  pus-cells, 
but  when  there  is  a  free  purulent  discharge  there  is  room  for  a  sus- 
picion that  the  cause  may  be  specific. 

This  form  of  cervical  endometritis  frequently  ends  in  recovery, 
but  may  become  chronic.  All  else  that  needs  to  be  said  on  this  sub- 
ject will  be  given  in  the  consideration  of  corporeal  endometritis. 

Acute  Corporeal  Endometritis. — Acute  corporeal  endometritis 
may  occur  alone,  but  I  have  always  found  it  accompanied  by  more 
or  less  cervical  endometritis. 

The  pathology  of  acute  non-specific  endometritis  I  consider  to 
be  a  hypersemia,  with  such  derangement  of  function  as  may  come 
from  it.  This  congestion  may  lead  to  swelling  of  the  mucous  mem- 
brane, destruction  of  its  epithelium  to  some  extent,  and  the  forma- 
tion of  pus,  but  these  changes  are  not  so  marked  as  they  are  in  me- 
tritis due  to  specific  causes.  There  is  derangement. of  the  menstrual 
function  ;  the  flow  may  be  retarded,  anticipated,  profuse,  or  scanty. 

A  free  menstruation  is  usually  very  beneficial.     Symptoms  often 


184  DISEASES   OF  WOMEN. 

subside  as  soon  as  a  free  flow  is  established,  and  if  this  flow  con- 
tinues the  usual  time  or  longer  the  patient  promptly  recovers.  Free 
menstruation  has  always  appeared  to  me  to  be  a  natural  means  of 
relief  in  this  affection. 

The  symptoms  and  physical  signs  of  cervical  and  corporeal  acute 
endometritis  are  similar  to  those  found  in  the  chronic  form  of  the 
affection,  and  to  save  repetition  these  points  will  be  taken  up  under 
the  head  of  chronic  endometritis. 

Prognosis. — This  is  favorable.  The  great  majority  of  cases  re- 
cover, and  the  worst  that  may  happen  is  that  the  disease  may  linger 
and  assume  the  chronic  form. 

Causation. — The  causes  which  give  rise  to  ordinary  inflammation 
of  mucous  membranes  generally  will  produce  acute  endometritis, 
especially  if  operative  at  or  near  the  menstrual  period.  Extreme^ 
sexual  excitation  or  over-indulgence,  exposure  to  cold,  over-fatigue, 
and  injuries  from  careless  examinations  with  the  touch  or  instru- 
ments, are  fair  examples. 

Treatment. — Complete  rest  is  the  first  and  most  important  ele- 
ment in  the  management.  To  quiet  the  nervous  system,  full  doses 
of  bromide  of  sodium  should  be  given.  This  may  also  relieve  pain. 
Should  the  suffering  still  persist,  opium  should  be  used,  but  not  if  it 
can  be  avoided  with  justice  to  the  sufferer. 

Hot  applications  should  be  made  over  the  hypogastrium.  Lin- 
seed-meal poultices,  covered  with  oil-silk,  should  be  preferred,  but  if 
the  patient  complains  of  the  weight,  flannels  wrung  out  of  hot  water 
may  be  used  in  the  same  manner.  The  hot-water  douche  should  be- 
used  twice  or  three  times  a  day  if  it  gives  relief.  The  bowels  should 
be  kept  free  with  saline  laxatives ;  should  these  cause  flatulence  and 
pain,  a  laxative  pill  of  colocynth  or  rhubarb  and  belladonna  will 
answer  better. 

This  simple  treatment  is  generally  suflicient.  More  heroic  meas- 
ures are  often  resorted  to.  but  usually  with  the  result  of  prolonging 
the  disease. 

Chronic  Cervical  Endometritis. —  Pathohujy. — In  cervical  endome- 
tritis, which  is  now  usually  called  uterine  catarrh,  there  is  very 
decided  congestion  and  hypersecretion  of  the  glands  of  the  cervix. 
This  secretion  differs  very  little  in  its  physical  properties  from  that 
which  is  normal,  except  that  it  is  excessive  in  quantity.  If  this 
congestion  is  long  continued,  the  exfoliation  of  epithelium  pro- 
gresses faster  than  its  replacement  by  the  development  of  new  cells, 
so  that  the  membrane  is  covered  with  young  epithelium  which  gives 
it  a  reddish  color. 


INFLAMMATORY   AFFECTIONS   OF   THE   UTERUS.  185 

Tliis  disturbance  of  the  balance  between  the  process  of  exfoliation 
and  reproduction  not  only  involves  tiie  mucous  membrane  of  the 
canal,  but  extends  outward  from  the  os  externum  about  half  the 
thickness  of  the  walls  of  the  cervix.  This  gives  rise  to  the  con- 
ditions which  were  described  by  the  older  writers  as  ulceration  of 
the  cervix  uteri. 

As  the  process  advances  the  mucous  membrane  becomes  thick- 
ened by  proliferation  of  the  areolar  tissue  and  by  distention  of  the 
blood-vessels,  so  that  it  becomes  too  large  for  the  surface  which 
it  covers ;  this  throws  it  into  the  fine  rugosities  or  wrinkles  which 
give  the  surface  a  granular  or  papillous  appearance.  These  pro- 
jecting points  were  supposed  by  the  older  pathologists  to  be  an 
enlargement  of  the  papillae  of  the  mucous  membrane,  but  it  is 
now  known  that  they  are  new  formations  due  to  areolar  hyper- 
plasia. It  is  supposed,  also,  that  the  glands  undergo  some  patho- 
logical change  other  than  mere  congestion,  but  probably  the  only 
change  is  a  congestion  and  modification  of  the  epithelium  which 
lines  them. 

It  is  claimed  by  some  that  new  glands  are  developed  upon  the 
outer  surface  of  the  cervix  around  the  os  externum ;  I  am  inclined 
to  think,  however,  that  the  glands  which  are  seen  outside  of  the  os 
externum  in  cervical  endometritis  appear  there  because  of  the  thick- 
ening of  the  mucous  membrane  which  causes  a  procidentia  or  pro- 
lapsus of  this  membrane. 

It  is  difficult  to  believe  that  the  inflammatory  process  could  lead 
to  the  development  of  new  anatomical  structures  of  a  normal  char- 
acter, but  there  is  strong  evidence  to  show  that  this  occurs  in  the 
mucous  membrane  of  the  cervix  uteri.  Sometimes  the  irregularity 
of  surface  due  to  hyperplasia  is  very  marked,  especially  in  cases 
where  there  is  laceration  of  the  cervix.  This  condition  has  been 
called  "granular  degeneration" — a  good  enough  name,  if  it  is  re- 
membered that  it  is  produced  by  a  throwing  up  of  the  membrane 
into  folds  or  projections  by  an  enlargement  and  thickening  due  to 
hyperplasia,  and  that  it  is  not  a  degeneration  in  fact. 

In  some  cases,  especially  those  that  have  been  treated  with  caus- 
tics, the  mouths  of  the  Nabothian  glands  become  closed  and  the 
glands  become  distended  by  their  secretion,  and  form  cyst-like  bodies 
deep  in  the  membrane.  These  are  usually  seen  at  the  surface  as 
whitish,  pearly -looking  points,  which  contrast  with  the  deep-red  color 
of  the  mucous  membrane  around  them.  To  the  touch  they  feel  like 
shot,  imbedded  in  the  membrane ;  these  have  long  been  known  as 
the  "ovulsB  Nabothi "- -more  recently  this  condition  has  been  called 


186 


DISEASES   OF  WOMEN. 


"  cystic  degeneration  of  tlie  cervix "  (Fig.  97).  Sometimes  one  or 
more  of  them  become  very  large,  and  by  pressure  cause  absorption 
of  the  middle  wall  of  the  uterus  around  them. 

The  hypersemia  sometimes  extends  to  the  middle  coat  of  the  cer- 
vix, and  then  for  a  time  the  tissues  are  softened  and  o^dematous. 


l,'i(..  1J7. — Section  through   the   iinicuiiH  meinbraue  of  the  vaginal  portion  of  the  cervix 
sho\vi)ig  cystic  degeneration. 

AVith  this  condition  there  is  usually  free  leucorrho?a  and  menor- 
rhagia,  especially  when  the  body  of  the  uterus  is  affected.  Occasion- 
ally, though  rarely,  the  menstrual  function  is  suspended  or  dimin- 
ished. In  some  cases  of  long  standing,  especially  when  there  is 
laceration  of  the  cervix,  the  areolar  hyperplasia  extends  to  all  the 
tissues  of  the  cervix,  giving  rise  to  that  induration  known  as  scle- 
rosis. 


INFLAMMATORY   AFFECTIONS   OF   THE   UTERUS. 


187 


Tliese  are  the  principal  pathological  conditions  ol>served  in  the 
ordinary  forms  of  cervical  endometritis.    Occasionally  the  discharge 


Fig  9"^ — H\pertrophv 
of  boih  of  uterus  fol- 
low ino;  coiporcal  endo- 
metntife  (Winckel). 


Fig.  100. — General  enlarge- 
ment of  uterus,  contrasting 
with  the  two  preceding  fig- 
ures (Winckel). 


Fig.  98.  —  Thickening  and 
elongation  of  the  cervix,  as 
a  result  of  cervical  endome- 
tritis (Winckel). 


may  be  muco  -  purulent,  at  times  it  is 
sero-muco-purulent ;  but  this  occurs  only 
in  extreme  cases,  and  usually  is  due  to 
some  specific  cause,  and  hence  need  not  be  considered  in  this  con- 
nection. 

The  ordinary  form  of  cervical  endometritis,  described  above, 
occurs  in  parous  and  imparous  alike.  There  is  another  form  of  cer- 
vical endometritis  which  occurs  only  in  the  imparous,  and  has  some 
peculiar  characteristics  which  should  l)e  noticed  here.  In  these  cases 
the  changes  in  the  vessels  already  noted  may  or  may  not  be  present ; 
usually  they  are  not.  The  discharge  from  the  cervical  canal  is  not 
usually  profuse,  but  it  is  peculiar  in  character.  In  place  of  the  clear, 
translucent  secretion  we  find  a  very  thick  and  exceedingly  tenacious 
material  of  the  consistency  of  thick  glue,  and  of  a  darkish  color  not 
unlike  pneumonic  sputum,  though  more  solid  and  dense,  and  not  usu- 
ally so  bright-red  in  color.     Associated  ^Yith  this  peculiar  discharge 


188  DISEASES  OF  WOMEN. 

there  are  usually  marked  tenderness  and  dysmenorrlioea,  which  are 
not  accounted  for  by  any  other  condition  of  the  uterus  than  the  state 
of  the  cervical  mucous  membrane.  I  am  inclined  to  think  that  this 
form  of  cervical  disease  is  due  to  some  malformation  or  arrest  of  de- 
velopment of  the  glands  of  the  mucous  membrane.  I  have  been  led 
to  believe  this  because  it  occurs  in  those  in  whom  the  uterus  is  im- 
perfectly developed  generally,  and  also  the  same  peculiar  secretion  is 
observed  in  some  women  after  the  menopause,  when  the  uterus  and 
its  mucous  membrane  have  undergone  final  involution. 

In  other  cases  of  this  class  the  mucous  membrane  of  the  cervix 
becomes  prolapsed,  causing  dilatation  and  inversion  of  the  lips  of 
the  external  os,  so  that  the  cervix  appears  as  if  it  had  sustained 
superficial,  bilateral  laceration.  In  such  cases  the  ai:)pearance  is  such 
as  to  lead  to  the  belief  that  the  patient  has  borne  children,  or  had  a 
miscarriage  ;  but  I  have  found  it  associated  with  unruptured  hymen, 
showing  that  it  could  not  have  come  from  injuries  during  parturition. 

Dr.  Emmet  describes  cases  of  laceration  that  he  has  seen  follow- 
ing criminal  abortion  in  those  who  have  not  borne  children.  In  the 
cases  to  which  I  refer  the  anatomical  appearances  are  the  same  as  he 
describes,  but  I  am  satisfied  that  in  those  that  have  come  under  my 
observation  the  laceration  was  apparent,  not  real.  As  soon  as  the 
membrane  is  reduced  to  its  normal  dimensions  by  exsection  of  a 
portion  of  it,  and  relief  of  the  inflammation  by  treatment  is  accom- 
plished, the  external  os  contracts,  and  the  cervix  resumes  its  original 
virgin  form,  showing  that  no  injury  to  the  muscular  coats  of  the 
uterus  has  ever  occurred. 

Symptomatology.  —  Cervical  endometritis  does  not  necessarily 
give  rise  to  marked  constitutional  disturbance ;  when  it  does  so  the 
symptoms  usually  appear  in  the  form  of  general  debility,  especially 
of  the  nervous  system.  The  patient  may  become  easily  fatigued 
and  somewhat  changed  in  disposition,  and  less  inclined  to  mental 
activity.  (Sometimes  there  is  considerable  mental  disturbance,  but 
much  of  all  this  is  usually  due  to  the  fact  that  the  patient  is  annoyed 
by  the  presence  of  a  more  or  less  profuse  leueorrhoea,  which  gives 
her  discomfort,  and  leads  her  to  suppose  that  she  is  suffering  from 
a  serious  affection.  The  constitutional  effects  of  this  local  affection 
depend  very  much  upon  the  sensitiveness  of  the  patient. 

The  menstrual  function  is  not  necessarilj^  affected.  In  cases  of 
long  standing  there  may  be  irregular  menstruation,  and  the  flow  may 
be  inclined  to  diminish,  but  this  is  not  the  rule. 

The  character  of  the  leucorrlueal  discharge  is  diagnostic.  It  is 
dense,  thick,  opaque,  and  tenacious,  while  the  vaginal  leucorrhoea  is 


INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS.  189 

serous,  non-tenacious,  and  usually  purulent.  If  the  disease  is  long 
continued  backache  comes  on,  the  pain  being  located  in  the  sacral 
region,  which  distinguishes  it  from  the  lumbar  pain  characteristic  of 
general  debility  and  some  of  the  acute  diseases.  There  is  often, 
also,  some  pelvic  tenesmus.  All  these  symptoms  are  usually  very 
much  aggravated  by  muscular  exercise;  the  symptoms  alone,  how- 
ever, are  not  sufficient  to  enable  one  to  make  a  diagnosis.  All  that 
can  be  learned  from  them  is  simply  that  there  is  some  uterine  affec- 
tion which,  if  it  does  not  yield  promptly  to  constitutional  treatment, 
demands  further  investigation  in  order  to  settle  definitely  its  char- 
acter. 

Physical  Signs. — These,  as  obtained  by  the  touch,  are  usually 
rather  unsatisfactory.  Upon  making  pressure  upon  the  cervix  there 
is  sometimes  tenderness,  but  not  always  ;  in  some  cases  a  roughened 
condition  of  the  mucous  membrane  around  the  os  externum  can  be 
detected  by  the  touch.  ]^ot  infrequently  there  is  a  little  relaxation 
of  the  vagina,  and  the  uterus  rests  lower  in  the  pelvis. 

Speculum  examination  affords  the  best  means  of  ascertaining  the 
lesions.  We  can  usually  see  enough  of  the  mucous  membrane  within 
the  OS  externum  to  determine  the  presence  of  the  inflammation. 
This  is  rendered  more  positive  when  the  redness  and  erosion  of  the 
membrane  extend  outward  upon  the  vaginal  surface  of  the  cervix, 
and  also  when  there  is  eversion  of  the  membrane.  There  is  usually 
a  free  leucorrhoeal  discharge  from  the  cervical  canal.  Sometimes  this 
hypersecretion  is  the  only  evidence  of  the  disease  present.  Passing 
the  sound  into  the  cervical  canal  shows  that  it  is  more  sensitive  than 
in  health,  and  the  membrane  bleeds  more  easily  on  touch  than 
it  should.  It  will  be  seen  that  the  physical  signs,  as  well  as  the 
symptoms,  are  not  by  any  means  marked  in  cervical  endometritis, 
yet  they  are  sufficient  for  diagnostic  purposes.  Whenever  the  con- 
stitutional disturbance  and  the  local  symptoms  are  severe,  it  may  at 
least  be  suspected  that  the  membrane  of  the  cavity  of  the  body  of 
the  uterus  is  also  involved.  This  will  be  more  fully  discussed  under 
the  head  of  corporeal  endometritis. 

In  the  form  of  cervical  endometritis  referred  to,  in  which  the 
secretion  of  the  glands  is  opaque,  dark  in  color,  and  exceedingly  te- 
nacious, the  discharge  is  not  at  all  times  very  profuse,  but  enough 
can  be  obtained  by  using  a  small  curette  to  show  its  character.  This 
in  itself  will  be  sufficient  to  determine  the  diagnosis. 

Causation. — The  predisposing  causes  of  endometritis  are  imper- 
fections in  the  general  organization,  and  in  the  development  and 
growth  of  the  sexual  organs.     Scrofulous  and  tubercular  diatheses 


190  DISEASES  OF   WOMEN. 

incline  to  chronic  inflammation  of  the  mucous  membranes  generally, 
and  the  membrane  of  the  uterus  is  no  exception. 

When  the  uterus  is  under  size  or  malformed  in  a  slight  degree, 
so  that  menstruation  is  imperfectly  performed,  an  inflammation  of 
its  mucous  membrane  is  very  likely  to  come  on  sooner  or  later.  Sed- 
entary habits  and  unsuitable  clothing,  over-fatigue  in  standing  or 
walking,  or  anj'thing  which  interrupts  the  return  circulation  from 
the  pelvis,  predispose  to  this  aifection.  So,  also,  deranged  nutrition, 
from  insufiicient  nutriment  or  over-taxation,  mental  or  physical, 
which  leads  to  impoverishment  of  the  blood.  Frequent  child-bearing 
and  prolonged  lactation  also  predispose  to  the  same  trouble.  All  these 
causes  act  to  produce  derangement  of  innervation  and  circulation, 
and  so  favor  the  development  of  inflammation. 

The  exciting  cause  which  plays  the  jnost  important  part  in  endo- 
metritis is  imperfect  involution  after  confinement  or  menstruation. 
The  great  majority  of  cases  take  their  origin  from  this  imperfection 
of  the  menstrual  or  parturient  involution. 

Other  exciting  causes  which  may  be  mentioned  are  injuries  to 
the  uterus  from  displacements,  the  use  of  ill-fitting  pessaries,  injuries 
during  confinement,  causing  puerperal  inflammations:  abortion,  es- 
pecially if  produced,  intemperate  coition,  and  efforts  to  prevent  con- 
ception, and  finally  gonorrhceal  virus.  This  specific  cause  of  endo- 
metritis no  doubt  produces  a  form  of  inflammation  which  difters 
from  the  non-specific  forms,  and  hence  we  will  refer  to  it  at  another 
time.  So  far  as  I  know  the  same  causes  produce  both  cervical  and 
corporeal  endometritis,  so  that  in  the  present  state  of  our  knowledge 
I  am  not  prepared  to  state  any  difference  in  the  causes  of  the  two 
affections,  if  any  such  exists.  I  am  inclined  to  think,  however,  that 
as  cervical  endometritis  is  beyond  doubt  much  more  common  than 
corporeal,  it  may  be  inferred  that  the  one  tends  to  the  development 
of  the  other. 

Prognosis. — Of  the  uncomplicated  cases  of  cervical  endometritis 
the  great  majority  yield  to  the  proper  treatment.  There  is  in  some 
a  tendency  to  a  recurrence  of  the  disease,  even  after  recovery  has 
apparently  been  perfect.  In  those  cases  of  imperfect  development 
there  is  not  the  same  certainty  of  giving  eomjilete  relief. 

Treatment. — The  constitutional  treatment  of  inflammatory  affec- 
tions of  the  uterus  should  be  based  upon  the  principles  of  the  gen- 
eral management  of  local  inflammations.  To  correct  any  defect  in 
the  general  health,  to  improve  menstruation,  and  to  calm  any  excite- 
ment of  the  nervous  system,  comprehends  the  whole  subject.  The 
sexual  organs  being  dependent  upon  the  nutritive  and  nervous  sys- 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  191 

terns  for  support,  general  therapeutic  agents  can  only  affect  tlie  one 
by  action  through  the  other. 

There  are  a  few  medicines  wliicli  act  especially  upon  the  sexual 
organs,  through  the  circulatory  or  nervous  systems,  such  as  ergot, 
hydrastis  canadensis,  and  the  bromides,  but  their  effects  are  not  al- 
ways efficient  in  controlling  inflammation. 

Constitutional  remedies,  as  already  stated,  act  upon  the  uteras 
only  so  far  as  they  improve  general  nutrition  and  innervation.  In 
view  of  these  facts,  little  need  be  said  on  this  part  of  the  subject ; 
every  means  which  can  improve  the  general  health  should  be  em- 
ployed in  connection  with  the  local  treatment.  To  save  repetition, 
the  reader  is  referred  to  the  section  on  menstrual  derangements, 
third  chapter,  for  details  of  constitutional  derangements  which  usu- 
ally accompany  diseases  of  the  uterus. 

Local  Treatment. — Local  treatment  of  the  diseases  of  the  uterus 
— the  one  organ  of  the  sexual  system  which  is  most  amenable  to  local 
treatment — will  be  given  in  the  history  of  cases.  Some  general  re- 
marks, however,  on  the  principal  facts  in  uterine  therapeutics  may 
be  submitted  in  this  connection.  That  which  is  said  now  will  apply 
in  great  part  to  all  forms  of  metritis. 

Local  treatment  should  be  employed  with  the  view  of  accom- 
plishing two  objects :  first,  to  remove  the  disease,  and,  second,  to 
restore  the  organ  to  its  normal  condition. 

It  will  at  once  be  inferred  that  if  the  first  object  is  attained,  the 
second  will  follow  as  a  natural  consequence  ;  but  it  may  or  may  not, 
according  to  the  character  of  the  treatment  employed.  I  am  satis- 
fied that  in  times  past,  and  even  at  present,  much  of  the  treatment 
of  uterine  disease,  while  it  arrests  the  inflammatory  trouble,  proves 
so  destructive  to  the  normal  structure  of  the  organ  as  to  render  the 
last  condition  of  the  patient  worse  than  the  first. 

In  the  management  of  uterine  diseases  one  may  be  guided  by 
some  of  the  accepted  rules  laid  down  by  surgeons  for  the  treatment 
of  infiamraation  generally,  viz. :  Place  the  diseased  organ  at  rest ; 
quiet  irritation  by  sedatives,  and  relieve  the  congestion  by  depletion, 
astringents,  alteratives,  and  sedatives.  To  accomplish  these  objects, 
it  is  necessary  to  employ  all  the  improved  means  brought  forward 
by  modern  investigation,  changing  and  adapting  them  so  as  to  meet 
the  peculiarities  of  each  case.  First,  then,  rest  should  be  secured  by 
having  the  patient  abstain  from  long-continued  standing  or  walking, 
and  from  over- excitement  of  the  sexual  function.  If  the  uterus  is 
displaced,  it  should  be  replaced,  and  sustained  in  its  normal  position 
by  the  support  of  a  well-fitting  pessary,  if  need  be. 


192  DISEASES  OF   WOMEN". 

To  relieve  pain  and  quiet  the  irritation  a  vaginal  or  rectal  sup- 
pository made  of  extract  of  belladonna,  one  eighth  to  one  half  grain, 
with  cocoa-butter,  and  used  at  bed-time,  will  often  give  great  relief. 
Suppositories  of  iodoform  and  of  conium  are  also  of  service  when 
used  in  the  same  way. 

I  desire  to  call  attention  specially  to  the  next  agent,  namely,  deple- 
tion, because  I  regard  it  is  as  a  remedy  of  some  value.  In  making  this 
statement  I  am  aware  that  I  encounter  much  professional  prejudice. 
Bloodletting  has  ceased  to  be  the  fashion  of  the  day.  The  lancet  is 
condemned  as  a  "  little  instrument  of  mighty  mischief."  Few  of 
the  younger  members  of  the  piofession  have  ever  seen  a  patient  bled. 
Local  depletion  held  its  own  some  time  after  general  venesection 
was  to  a  great  extent  abandoned,  but  even  this  has  gradually  given 
way  to  the  popular  prejudice  of  the  day ;  nevertheless,  the  fact  in 
surgical  therapeutics  remains  as  true  as  ever,  that  the  removal  of 
blood  directly  from  the  vessels  of  an  iuilanied  or  congested  organ 
gives  some  temporary  relief. 

Frequent  repetition  of  bloodletting  should  be  avoided,  but  when 
a  case  is  first  seen  in  which  there  is  marked  congestion,  the  abstrac- 
tion of  a  httle  blood  by  a  few  punctures  around  the  os  externum,  or 
the  superficial  scarification  of  the  mucous  membrane  in  this  region 
will  pave  the  way  for  other  applications. 

To  practice  depletion  exclusively  and  persistently,  as  some  of  the 
older  gynecologists  did,  is  certainly  injurious ;  but,  as  a  means  to  be 
employed  in  suitable  cases,  it  is  worthy  of  consideration. 

Hot  water,  used  as  a  vaginal  douche,  is  an  antiphlogistic  which 
was  first  popularized  in  this  country  by  T.  A.  Emmet.  It  depletes 
the  parts  by  stimulating  the  circulation,  and  is  at  the  same  time 
something  of  a  local  sedative.  It  is  an  exceedingly  jjopnlar  remedy 
at  the  present  time,  and  is  used  rather  indiscriminately  in  all  diseases 
of  the  pelvic  organs,  and  with  heroic  persistency.  If  properly  used 
it  gives  relief  in  congestion  of  the  vagina  and  uterus,  and  in  cellulitis 
when  the  inflammation  is  limited  to  the  cellular  tissue  about  the  cer- 
vix uteri.  It  is  also  of  service  in  the  passive  congestion  which  often 
accompanies  imperfect  involution,  but  in  pelvic  peritonitis,  salpin- 
gitis, and  ovaritis  it  is  often  harmful. 

It  is  also  very  liable  to  do  harm  when  used,  as  it  often  is,  after 
plastic  operations  about  the  cervix  uteri  and  perinaium. 

Another  means  of  depletion  was  introduced  by  J.  Marion-Sims. 
He  employed  a  small  vaginal  tampon  of  cotton  saturated  with  glyc- 
erin, which  caused  free  exosmosis  from  the  mucous  membrane,  there- 
by relieving  capillary  engorgement  and  oedema. 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  193 

Position  has  much  influence  in  modifying  the  circulation  in  the 
pelvis,  and  hence  patients  should  avoid  the  too  common  habit  of  sit- 
ting all  day  in  a  chair  because  they  suffer  when  they  walk.  Short 
periods  of  walking  or  riding,  followed  by  rest  in  the  recumbent  po- 
sition, should  be  directed. 

In  the  treatment  of  endometritis  with  the  applications  of  cura- 
tive agents,  two  very  important  questions  arise :  First,  what  agents 
shall  be  used,  and  how  shall  they  be  applied.  Bearing  in  mind  that 
the  uterus  should  not  be  injured  in  its  structure,  the  therapeutist  is 
bound  to  reject  all  the  more  powerful  and  destructive  agents,  such 
as  nitric  or  chromic  acid,  caustic  potash,  and  the  actual  cautery.  All 
these  have  been  used,  and  are  now,  though  less  extensively,  I  trust, 
than  formerly,  in  the  treatment  of  simple  chronic  endometritis,  or 
hypersemia  of  the  mucous  membrane  of  the  cavity  of  the  uterus. 

Leaving  out  of  account  the  value  of  these  potent  agents  in  the 
treatment  of  malignant  diseases  of  the  uterus,  I  desire  to  be  distinctly 
understood  as  opposed  to  their  use  in  the  treatment  of  the  benign 
uterine  diseases. 

I  readily  admit  that  inflammation  of  a  mucous  membrane  can 
and  may  have  been  "  cured,"  as  the  expression  is,  by  such  means. 

The  oculist  could  "  cure  "  a  chronic  conjunctivitis  by  destroying 
the  membrane  with  strong  caustic,  but  I  fear  the  eye  would  be  hardly 
presentable  afterward,  and  it  would  surely  fail  to  perform  its  func- 
tion. There  are  those  who  treat  the  same  affections  of  the  mucous 
membrane  of  the  uterus  with  these  destructive  agents,  and  the  results 
which  follow  can  be  easily  imagined.  It  may  be  argued,  I  am  aware, 
that  strong  caustics  are  being  used  less  and  less  by  the  profession  in 
the  treatment  of  uterine  disease,  and  I  am  glad  to  believe  that  such 
is  the  case.  Nitric  and  chromic  acids,  and  other  caustics,  are  being 
laid  aside,  but  only,  I  fear,  to  give  place  in  some  cases  to  new  but 
none  the  less  destructive  agents.  I  allude  to  the  galvano-cautery  and 
the  thermo-cautery.  These  have  become  the  "  fashionable  "  caustics 
or  cauteries  of  the  day,  and  I  trust  I  most  thoroughly  appreciate  their 
value  in  the  treatment  of  malignant  disease,  when  the  destruction  of 
tissue  is  called  for ;  but,  in  the  treatment  of  inflammation,  they  can 
not  fail  to  work  great  and  uncalled-for  destruction,  like  the  agents 
used  in  the  past. 

The  treatment  of  the  cervical  canal  is  fortunately  simpler,  being 
m.ore  easy  to  reach,  and  much  more  tolerant  of  irritation.  The  only 
difficulty  in  the  way  of  making  applications  is  the  presence  of  a  tena- 
cious secretion  which  fills  the  canal.  This  should  be  removed  with 
a  small  curette  before  the  application  is  made. 
14 


19-1:  DISEASES  OP  WOMEN. 

The  method  of  applying  these  agents  is  by  using  the  pipette 
(Fig.  101).     Regarding  the  agents  to  be  used,  a  long  list  might  be 

^_  given,    but   it   will 

-^  r■T^i:^^AN^l,&■^.u■^.^^^^^^    suffice    tO    say    that 

^J^^"^  ^  the  safest  and  most 

Fig.  101. — Skene's  instillation  tube.  . 

emcient    are    mild 

solutions,  one  or  two  grains  to  the  ounce,  of  sulphate  of  zinc,  chlo- 
ride of  zinc,  nitrate  of  silver,  tannic  acid,  and  bichloride  of  mer- 
cury ;  mv  own  preference  for  general  use  is  tincture  of  iodine  two 
parts  and  carbolic  acid  one  part. 

The  frequency  with  which  these  local  applications  should  be  made 
depends  upon  the  nature  of  the  lesions.  In  ordinary  cervical  and 
corporeal  endometritis,  once  every  five  or  six  days  will  answer.  This 
gives  time  for  the  tissues  to  fully  profit  by  the  application  before 
it  is  repeated. 

I  am  aware  that  the  practice  with  some  is  to  make  local  applica- 
tions every  day  or  every  other  day,  but  I  know  that  this  constant 
manipulation  is  irritating,  and  does  more  harm  than  good. 

Mucous  Polypi  of  the  Cervix  Uteri. — In  connection  with  erosion 
of  the  cervix  the  glands  of  the  cervical  canal  sometimes  become 
cystic,  and  project  from  the  eroded  surface.  The  amount  of  this 
projection  is  occasionally  so  great  that  the  cysts  escape  from  the 
canal  and  hang  by  pedicles  in  the  vagina.  They  are  not  unlike 
nasal  polypi,  and  are  called  mucous  polypi  of  the  cervix.  They  are 
red  in  color  and  are  semi-transparent. 

ILLUSTKATIVE    CASES. 

A  Typical  Case  of  Uncomplicated  Cervical  Endometritis. — A  lady, 
thirty-two  years  of  age,  was  married  at  the  age  of  twenty-one,  had 
borne  six  children,  and  had  nursed  all  of  them.  Her  health  had 
always  been  very  good,  and  her  menstruation  regular  and  natural, 
showing  that  her  general  health  and  organization  were  excellent. 
She  nursed  her  last  child  for  eighteen  months,  her  menses  returning 
when  her  child  was  ten  months  old.  From  that  time  she  had  a  slight 
leucorrhojal  discharge,  which  gave  her  no  trouble  and  was  not  re- 
garded. Before  weaning  her  child  she  became  quite  debilitated,  com- 
]ilaining  of  occasional  dizziness,  shortness  of  breath  in  active  exer- 
cise, considerable  backache,  constipation,  and  occasionally  impaired 
appetite.  Her  leucorrhoea  about  this  time  increased  in  amount  and 
alarmed  her,  because  she  attributed  her  general  ill-feelings  to  this 
discharge.  This  was  her  condition  when  she  first  applied  for  advice. 
On  digital  examination  the  uterus  was  found  to  be  normal  in  size 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  195 

and  position,  the  external  os  was  larger  than  normal,  and  there  ap- 
peared to  be  slight  roughening  of  the  membrane  immediately  around 
the  OS.  A  specuhim  examination  revealed  an  areola  of  a  deep-red 
color  around  the  os  externum,  and  a  profuse  leucorrhoeal  discharge 
from  the  cervical  canal.  The  cervix  appeared  to  be  a  little  larger 
than  normal,  but  this  increase  in  size  V7as  wholly  due  to  enlargement 
of  the  cervical  mucous  membrane,  which  was  decidedly  congested, 
and  possibly  somewhat  thickened.  The  internal  os  appeared  to  be 
normal ;  the  mucous  membrane  of  the  cervix  bled  when  touched 
rather  gently  with  the  uterine  sound.  From  the  fact  that  her  men- 
strual flow  was  quite  regular  and  normal,  and  that  the  internal  os 
was  not  unduly  dilated,  nor  the  body  of  the  uterus  enlarged  or  ten- 
der, the  diagnosis  of  endometritis  limited  to  the  cervix  was  made 
with  positiveness.  Her  general  debility  was  no  doubt  due  to  fre- 
quent child-bearing  and  lactation,  and  not  wholly  to  her  uterine  dis- 
ease, as  she  had  supposed ;  in  fact,  I  believe  that  the  cause  of  the 
endometritis  was  largely,  perhaps  entirely,  due  to  her  exhausted  and 
debilitated  condition. 

,  She  was  directed  to  wean  her  child  as  promptly  as  possible,  and 
to  rest  from  all  her  taxing  household  duties ;  to  spend  some  time 
every  day  in  the  open  air,  riding  mostly,  and  to  take  an  abundance 
of  good  nourishing  food.  The  following  prescriptions  were  given 
to  her :  A  teaspoonful  of  comp.  liquorice-powder  at  bed-time,  to  be 
repeated  every  night,  the  quantity  to  be  increased  or  diminished  in 
order  to  keep  the  bowels  regular.  Two  grains  of  the  pyrophosphate 
of  iron  were  given  after  meals,  well  diluted,  and  a  glass  of  claret. 
Locally,  she  was  directed  to  use  a  vaginal  douche  of  borax  and  wanii 
water  twice  a  day.  This  was  continued  for  about  two  weeks,  M^hen 
it  was  found  that  she  did  not  apparently  derive  very  much  benefit  from 
it,  and  she  was  directed  to  use  it  only  once  a  day,  which  seemed  to 
answer  quite  as  well,  and  relieved  her  from  the  trouble  of  using  it 
twice  a  day,  which  she  complained  of  as  a  considerable  annoyance. 
Locally,  the  treatment  consisted  of  a  careful  removal  of  all  secretions 
from  the  cervical  canal  with  a  dull  curette.  In  doing  this  consider- 
able hseraorrhage  was  produced  at  first,  and  it  was  necessary  to  wait 
until  this  had  subsided  before  making  any  local  application,  but  as 
this  only  occurred  a  few  times  it  was  soon  possible  to  remove  the 
secretions  without  difficulty,  and  a  preparation  of  equal  parts  of 
tincture  of  iodine  and  carbolic  acid  was  applied  thoroughly  to  the 
entire  canal  with  the  glass  pipette  (Fig.  96).  A  few  drops  of  this 
mixture  was  drawn  up  into  the  tube  by  compressing  and  releasing 
the  bulb.     The  pipette  was  carried  up  to  the  internal  os,  and  while 


196  DISEASES  OF  WOMEN. 

it  was  being  slowly  withdrawn  pressure  was  made  upon  the  rubber 
bulb,  which  gently  expelled  this  mixture  and  thoroughly  applied  it 
to  the  entire  raucous  membrane.  This  local  treatment  was  repeated 
every  five  days  during  the  next  two  succeeding  inter-menstrual  pe- 
riods, and  the  general  tonic  and  sustaining  treatment  continued, 
varying  the  chalybeate  tonics  from  time  to  time.  From  this  time 
onward  local  applications  were  made  after  each  menstrual  period, 
and  again  in  about  two  weeks,  making  two  local  treatments  between 
each  menstrual  period.  Her  general  condition  greatly  improved ; 
the  cervix  diminished  in  size  by  a  marked  contraction  of  the  cali- 
ber of  the  canal ;  the  leucorrhoeal  discharge  almost  entirely  disap- 
peared, and  at  the  end  of  five  months  from  the  time  that  the  treat- 
ment was  first  begun  she  was  dismissed  quite  well.  She  was  di- 
rected, however,  to  return  after  the  menstrual  period  for  two  or 
three  months,  to  ascertain  if  there  was  any  disposition  to  a  recurrence 
of  the  cervical  endometritis.  It  was  found  that  she  remained  well, 
and  hence  recovery  was  considered  to  be  complete. 

Cervical  Endometritis,  with  Hyperplasia  of  the  Mucous  Membrane. 
— This  patient  was  twenty-eight  years  of  age,  rather  small  and  deK- 
cate-looking,  but  had  enjoyed  good  health  up  to  her  last  confinement. 
She  had  been  married  eight  years  and  had  three  children,  the  last 
one  being  ten  months  old  at  the  time  when  I  saw  her  first ;  she  had 
nursed  all  her  children,  the  first  two  for  about  a  year,  but  the  last 
one  she  weaned  when  it  was  eight  months  old,  because  she  did  not 
feel  well,  and  had  not  sufficient  milk  for  it.  When  her  baby  was 
about  four  months  old  she  began  to  suffer  from  leucorrhoea,  back- 
ache, and  pelvic  tenesmus — the  latter  symptoms  being  very  much 
aggravated  by  active  exercise.  She  had  also  lost  considerable  flesh, 
was  easily  fatigued,  and  somewhat  nervous  and  depressed ;  her  gen- 
eral nutrition  appeared  to  be  fair,  and  her  appetite  was  good ;  her 
bowels  were  regular,  and,  although  her  pulse  was  not  strong,  she  had 
a  good,  clear,  healthy  complexion.  Digital  examination  revealed 
slight  relaxation  of  the  vagina,  especially  of  the  upper  portion  ;  the 
uterus  was  rather  low  in  the  pelvis,  and,  while  the  body  was  normal 
in  size,  the  cervix  was  considerably  enlarged. 

The  cervical  canal  was  dilated,  and  the  lips  of  the  external  os 
everted.  Around  the  os,  and  extending  outward  to  about  half  the 
thickness  of  the  cervical  walls,  the  mucous  membrane  was  quite 
granular  and  rough  to  the  touch.  Through  the  speculum  a  very  free 
leucorrhoeal  discharge  from  the  cervix  was  observed,  and  the  first 
impression  was  that  there  was  superficial  bilateral  laceration  of  the 
cervix,  but  on  more  careful  investigation  it  was  found  that  the  mus- 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  197 

cular  wall  of  the  uterus  was  very  little,  if  at  all,  injured,  and  that 
the  enlargement  of  the  os  externum  and  the  eversion  of  its  lips  were 
due  to  the  enlargement  of  the  mucous  membrane. 

The  corrugations  of  the  thickened  mucous  membrane  were  so 
marked  as  to  give  a  papillomatous  appearance,  and  the  congestion 
was  such  that  the  parts  bled  freely  on  being  touched  with  a  sponge. 
The  patient  was  put  upon  a  systematic  course  of  rest  and  exercise, 
simple  but  nourishing  food,  and  the  citrate  of  iron  and  quinine  as  a 
tonic.  Locally,  she  was  ordered  a  vaginal  douche  of  two  quarts  of 
water,  two  drachms  of  borax,  and  a  half  drachm  of  tannic  acid  to 
be  used  twice  daily.  A  number  of  the  more  prominent  points 
of  the  mucous  membrane,  which  projected  from  tlie  os  externum, 
were  removed  with  the  scissors.  A  borated  tampon  was  introduced 
and  removed  on  the  following  day,  and  two  days  afterward  the  iodine 
and  carbolic  acid  mixture  was  applied  to  the  whole  length  of  the  cer- 
vical canal  with  the  pipette.  One  week  afterward  that  portion  of  the 
cervical  mucous  membrane  which  could  be  seen  was  smooth,  less  re- 
dundant and  less  vascular ;  the  canal  was  still  dilated,  and  the  rugosi- 
ties of  the  mucous  membrane  were  abnormally  prominent.  The 
more  prominent  portions  of  the  mucous  membrane  of  the  canal  were 
touched  with  a  fifty-per-cent  solution  of  chloride  of  zinc  applied 
with  a  camel's-hair  brush.  Considerable  pain  followed  this  applica- 
tion, and  continued  until  late  in  the  evening.  From  this  onward 
the  vaginal  douche  was  employed  once  a  day,  borax  and  water  only 
being  used,  the  tannic  acid  being  omitted.  The  carbolic  acid  and 
iodine  were  applied  to  the  canal  of  the  cervix  with  the  pipette,  the 
secretion  being  carefully  removed  with  the  curette  before  the  appli- 
cation. This  local  treatment  was  employed  once  a  week  during  the 
inter-menstrual  periods  for  about  five  months,  after  that  one  appli- 
cation after  each  menstrual  period  for  three  months  longer.  At  this 
time  her  general  health  had  been  considerably  restored,  the  canal  of 
the  cervix  had  returned  to  its  normal  size,  the  leucorrhoeal  discharge 
had  entirely  disappeared,  and  the  mucous  membrane  around  the  os 
externum  was  perfectly  normal.  She  had  no  further  trouble  from 
backache  or  pelvic  tenesmus,  and  she  was  dismissed  perfectly  well, 
locally  and  generally. 

Cervical  Endometritis,  Stenosis  of  the  External  Os,  and  Cystic  De- 
generation of  the  Mucous  Membrane. — This  patient  was  an  English 
lady,  thirty-nine  years  of  age.  She  had  two  children,  the  youngest 
one  being  five  years  old.  She  had  an  excellent  constitution,  and  her 
health  had  always  been  quite  perfect.  After  her  second  confinement 
her  convalescence  was  interrupted  for  a  short  time  by  some  local 


198  DISEASES  OF  WOMEN. 

trouble,  the  nature  of  which  I  coukl  not  exactly  determine.  She 
recovered  from  this,  but  afterward  suffered  from  uterine  leucorrhoea. 
This  gave  her  very  little  trouble,  and  as  she  hoped  that  it  might  dis- 
appear she  did  not  seek  medical  advice  until  two  years  afterward, 
when  she  called  upon  a  physician,  who  told  her  that "  she  had  ulcer- 
ation of  the  womb."  He  treated  her  for  about  six  months  by  apply- 
ing nitrate  of  silver,  making  the  applications  with  a  swab  through  a 
cylindrical  speculum.  This  I  learned  from  the  patient  herself,  who 
stated  that  the  doctor  told  her  he  was  using  nitrate  of  silver. 

The  treatment  diminished  the  leucorrhoeal  discharge,  but  she 
began  to  have  backache  and  pelvic  tenesmus,  with  an  occasional 
sharp  pain  in  the  region  of  the  uterus.  She  also  had  slight  dys- 
pareunia.  She  was  told  by  her  physician  that  the  ulceration  was  cured, 
and  that  her  symptoms  would  all  probably  pass  away,  but  after  wait- 
ing for  six  months  and  finding  that  they  did  not  she  came  under 
my  observation.  Her  general  health  was  still  fairly  good,  but  the 
local  symptoms  caused  her  considerable  nervous  disturbance,  and  the 
leucorrhoea  had  returned,  but  not  so  profusely  as  before.  The  touch 
revealed  an  enlargement  of  the  cervix  uteri,  and  around  the  os  there 
was  a  number  of  quite  hard  points,  some  of  them  projecting  a  little 
above  the  general  surface,  giving  an  impression  that  there  was  a 
number  of  shot  imbedded  in  the  cervix.  The  os  externum  could 
not  be  very  clearly  made  out  by  the  touch.  The  entire  cervix  ap- 
peared to  be  a  little  denser  than  normal,  and  on  speculum  exami- 
nation the  mucous  membrane  seemed  to  be  red  in  spots,  while  the 
cysts  had  a  whitish  or  pearly  appearance,  some  of  them  showing  a 
deep-yellow  color.  The  os  externum  was  somewhat  puckered  from 
scar  tissue,  one  well-marked  scar  running  from  the  posterior  lip  of 
the  08  outward  and  backward.  This  was  lighter  in  color  than  the 
general  mucous  membranCo  The  os  admitted  a  small  uterine  probe. 
The  canal  of  the  cervix,  above  the  contracted  os  externum,  was  found 
to  be  considerably  dilated,  and  contained  quite  a  large  accumulation 
of  a  thick,  tenacious,  leucorrhoial  secretion.  The  cervix  was  tender 
to  the  touch,  but  not  extremely  so ;  the  body  of  the  uterus  appeared 
to  be  normal  in  every  way. 

The  conditions  here  found  illustrate  a  very  common  class  of  cases 
in  which  there  has  been  ordinary  cervical  catarrh,  which  has  been 
treated  by  the  application  of  a  caustic  to  the  vaginal  surface  of  the 
cervix  and  the  lips  of  the  os  externum. 

The  frequent  and  long-continued  use  of  nitrate  of  silver  almost 
always  produces  stricture,  scar  tissue,  occlusion  of  the  Nabothian 
glands,  and  the  formation  of  cysts.     The  treatment  in  this  case 


INFLAMMATORY  AFFECTIONS  OF   THE   UTERUS.  I99 

was  to  first  take  out  a  triangular  piece  of  the  scar  tissue  from  each 
side  of  the  os  externum,  which  enlarged  it  sufficiently.  The  cysts 
were  then  all  carefully  torn  open,  and  the  contents  evacuated  by 
pressure ;  the  secretion  in  the  cervical  canal  was  removed  with  the 
curette,  and  an  application  of  the  tincture  of  iodine  was  made  to  the 
canal  and  the  vaginal  portion  of  the  cervix.  A  hot-water  douche 
was  directed  to  be  used  twice  a  day.  The  patient  was  examined 
three  days  after,  when  the  os  externum  was  observed  to  be  contract- 
ing somewhat  as  the  healing  process  was  going  on.  A  small  tampon 
of  cotton  was  introduced  into  the  os  externum,  and  maintained  there 
for  twenty-four  hours  by  means  of  the  vaginal  tampon.  It  was  then 
reintroduced  without  the  vaginal  tampon,  and  again  removed  at  the 
end  of  the  next  twenty-four  hours.  This  tampon,  while  it  pre- 
vented the  contraction  of  the  os,  interfered  at  the  same  time  with 
the  process  of  healing,  so  it  was  given  up.  At  the  end  of  a  week 
after  the  tirst  treatment  there  was  found  still  a  number  of  cysts, 
some  of  them  within  the  cervical  canal.  These  were  all  opened  and 
the  leucorrhceal  secretion  removed  from  the  canal  with  the  curette, 
and  the  mixture  of  iodine  and  carbolic  acid  applied ;  and  tincture  of 
iodine  alone  applied  to  the  vaginal  portion  of  the  cervix. 

These  applications  were  repeated  once  a  week,  and  the  warm- 
water  douche  continued   for  four  months.      During  this  time  all 
the  local  symptoms  disappeared  except  the  leucorrhoeal  discharge,, 
and  this  diminished  in  quantity  and  became  less  opaque  in  character, 
but  it  did  not  wholly  disappear. 

The  size  of  the  external  os  remained  ample,  while  the  canal  con- 
tracted very  decidedly,  so  that  it  was  almost  of  its  normal  caliber. 
The  scar  tissue  became  less  dense,  and  all  tenderness  disappeared. 
After  the  first  four  months'  treatment  the  patient  was  seen  for  an- 
other three  months,  just  after  the  menstrual  period,  when  the  iodine 
and  carbolic  acid  were  applied  to  the  cervical  canal,  and  the  iodine 
to  the  vaginal  portion  of  the  cervix.  Seven  months  from  the  time 
that  she  first  came  under  my  observation  she  was  found  to  be  preg- 
nant, and  hence  was  dismissed  as  recovered.  I  subsequently  learned 
that  she  passed  safely  through  her  confinement,  but  1  have  had  no 
opportunity  of  examining  her  since,  although  I  believe  that  she  re- 
mains quite  well,  and  hence  it  can  be  inferred  that  the  cure  was 
permanent. 

Cervical  Endometritis  treated  by  Caustic,  which  produced  Con- 
traction of  the  lower  two  thirds  of  the  Cervical  Canal. — This  lady 
was  twenty-eight  years  of  age,  of  remarkably  strong  organization, 
and  had  always  enjoyed  good  health  until  the  birth  of  her  third 


200  DISEASES  OP  WOMEN. 

child.  At  that  time  she  had  some  difficulty  in  her  labor,  and  sus- 
tained a  slight  laceration  of  the  perinaeum ;  after  this  she  had  pelvic 
tenesmus  and  leucorrhosa.  When  she  first  came  under  my  observa- 
tion she  had  slight  prolapsus  of  the  uterus,  with  retroversion  in  the 
first  degree ;  there  was  cervical  endometritis,  indicated  by  the  deep- 
red  color  of  the  mucous  membrane  and  free  leucorrhoea,  but  there 
was  no  other  pathological  change  in  the  mucous  membrane.  An 
application  of  tannin  and  glycerin  was  made  to  the  cervical  canal, 
the  uterus  was  replaced,  and  she  was  told  that  it  would  be  necessary 
to  restore  the  perinaeum  in  order  to  give  complete  relief.  The 
thought  of  an  operation  somewhat  disturbed  her  mind,  and  a  friend 
advised  her  to  place  herself  under  the  care  of  her  physician,  a  homoe- 
opathist.  This  she  did,  and  at  the  second  visit  he  told  her  that  he 
had  introduced  a  pencil  of  nitrate  of  silver  into  the  womb,  and  had 
applied  some  cotton  to  keep  it  there,  and  desired  her  to  return  to 
his  office  the  next  day  so  that  he  might  remove  the  cotton.  On  the 
way  home  she  suffered  severe  pain,  and  was  obliged  to  go  to  bed  as 
soon  as  she  reached  the  house.  She  suffered  considerably  during 
the  night,  and  the  following  day  sent  for  the  physician,  who  removed 
the  cotton,  and  told  her  that  she  would  be  all  right.  She  continued, 
however,  to  have  a  good  deal  of  pain  and  pelvic  tenesmus,  especially 
when  she  tried  to  stand  or  walk.  For  the  next  two  or  three  days 
she  had  a  discharge  which  differed  from  the  former  leucorrhoea ;  it 
was  less  tenacious,  yellow  in  color,  and  at  times  quite  offensive  in 
odor.  She  returned  to  the  physician  for  further  treatment  as  soon 
as  she  was  able.  The  discharge  became  very  much  less,  and  finally 
disappeared  entirely.  She  was  encouraged  to  hope  that  she  would 
get  well  without  any  further  treatment.  In  this,  however,  she  was 
misled.  Her  backache  and  pelvic  tenesmus  increased  in  severity, 
especially  when  standing  or  walking,  and  she  began  to  have  painful 
menstruation.  About  a  year  from  the  time  she  had  the  caustic  ap- 
plied she  returned  to  me.  I  found  the  displacement  about  the 
same ;  there  was  no  leucorrhoeal  discharge  whatever,  and  no  external 
evidence  of  the  former  endometritis.  The  os  externum  was  con- 
tracted, and  its  lips  curved  inward ;  the  tissues  around  the  os  were 
extremely  hard,  and  to  the  touch  and  inspection  appeared  to  be  mostly 
scar  tissue. 

The  cervical  canal  was  contracted  in  its  lower  two  thirds,  so  that 
a  small  uterine  sound  could  be  passed  with  difficulty ;  there  was 
none  of  the  elasticity  of  the  normal  canal  left,  but  a  hard,  almost 
cartilaginous  condition  existed.  The  passing  of  the  sound  caused 
considerable  pain,  and  some  haemorrhage.     The  patient  was  then 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  201 

sent  to  mj  private  hospital,  and  an  effort  was  made  to  dilate  the 
cervix  by  the  use  of  graduated  sounds.  This  gave  pain,  and  was 
not  effectual.  Then  the  whole  length  of  the  contracted  portion  of 
the  cervical  canal  was  incised  on  the  two  sides,  the  incisions  being 
made  with  my  hysterotome  (Fig.  42)  through  the  scar  tissue,  and 
the  canal  was  then  dilated  sufficiently  to  admit  a  No.  23  sound  ; 
a  tent  made  of  marine  lint  and  dipped  in  carbolic  acid  and  glycerin, 
one  part  of  the  former  to  three  of  the  latter,  was  passed  up  into  the 
canal  and  retained  there  by  a  vaginal  tampon ;  this  was  left  in  po- 
sition for  twenty-four  hours,  when  it  was  removed.  A  short,  hard- 
rubber  stem-pessary,  which  reached  beyond  the  line  of  contraction, 
but  not  up  to  the  internal  os,  was  introduced  and  worn  for  nearly 
three  weeks.  During  that  time  it  was  repeatedly  removed  and  tinct- 
ure of  iodine  applied  to  the  cervical  canal,  and  a  vaginal  douche  of 
borax  and  warm  water  was  used.  The  treatment  was  continued 
throughout  with  all  antiseptic  precautions.  After  the  operation  on 
the  cervix  the  uterus  was  kept  in  place,  first  by  means  of  a  tampon, 
and  subsequently  by  means  of  the  pessary,  which  answered  the 
purpose  while  the  patient  remained  in  a  recumbent  position.  The 
perinseum  was  then  restored,  and  the  patient  dismissed  after  two 
months  of  treatment  in  the  institution.  She  subsequently  returned 
to  me  once  a  month,  when  I  passed  the  uterine  sound  and  applied 
the  tincture  of  iodine,  in  order  to  prevent  any  recurrence  of  the  con- 
traction. Six  months  from  the  time  that  she  was  operated  upon  she 
became  pregnant,  and,  although  some  trouble  was  anticipated  in  the 
dilatation  of  the  cervix  during  her  labor,  there  was  none.  Prof. 
Charles  Jewett  attended  her  in  her  confinement,  and  all  went  well, 
and  she  has  remained  free  from  uterine  trouble  ever  since. 

Cervical  Endometritis  in  an  Imparous  Woman. — This  was  a  cul- 
tivated lady,  with  an  excellent  constitution,  who  began  to  menstruate 
at  fourteen,  while  she  was  a  school-girl,  and  continued  to  do  so  nor- 
mally until  she  had  been  teaching  several  years  in  a  high  school. 
She  taught  many  hours  daily,  and  being  strong  and  very  ener- 
getic she  preferred  to  stand,  as  a  rule,  while  drilling  her  class.  This 
overtaxation  brought  on  dysmenorrhoea,  backache,  and  leucorrhoea. 
These  symptoms  were  not  marked  at  first,  but  as  she  kept  on  at  her 
work  they  gradually  increased.  When  she  was  twenty-eight  years 
of  age  she  came  under  my  care.  She  had  then  been  married  about 
one  year,  and  although  her  symptoms  had  not  increased — in  fact, 
she  had  enjoyed  better  health  after  being  relieved"  from  her  arduous 
duties  as  a  teacher — still  she  had  backache  and  leucorrhoea,  especially 
on  taking  active  exercise ;  and  she  was  sterile.     I  found  the  men- 


202  DISEASES  OP  WOMEN. 

strnal  function  perfectly  normal,  except  that  she  had  backache  and 
some  pelvic  tenesmus  during  the  flow,  but  these  were  relieved  to 
some  extent  if  she  kept  quiet.  Her  chief  symptom  at  that  time  was 
a  rather  free  leucorrhoea.  A  digital  examination  found  the  pelvic 
organs  well  developed.  There  was  no  tenderness  nor  any  evidence 
of  disease  that  could  be  obtained  by  the  touch,  except  that  the  os 
externum  appeared  to  be  larger  than  is  usually  found  in  the  virgin 
cervix.  On  speculum  examination  quite  a  free  leucorrhoeal  dis- 
charge was  observed,  and  there  was  a  ring  of  deep-red  color  in  the 
mucous  membrane  around  the  os  externum.  The  cervix  was  rather 
large  in  proportion  to  the  body  of  the  uterus,  and  was  of  a  deeper  color 
than  normal,  and  the  uj)per  portion  of  the  vagina  also  was  congested. 
The  canal  of  the  cervix,  including  the  internal  os,  was  normal  in 
size,  so  that  the  uterine  sound  could  be  passed  to  the  fundus  without 
dithculty  or  causing  much  pain.  As  her  health  was  quite  good,  no 
constitutional  treatment  was  necessary.  During  the  succeeding  two 
months  six  applications  of  iodine  and  carbolic  acid  were  made  to  the 
cervical  canal.  The  next  month  three  applications  were  made  of 
iodine  alone,  and  the  next  month  after  that  glycerin  and  tannic  acid 
were  applied.  At  the  end  of  that  time  the  leucorrhoeal  discharge 
had  entirely  subsided,  the  patient  suffered  much  less  from  backache, 
and  had  no  pain  or  discomfort  at  her  menstrual  periods.  She  was 
then  dismissed,  and  nothing  more  was  heard  of  her  until  four  years 
afterward,  when  she  returned  to  inform  me  that  she  was  two  months 
pregnant.  I  have  not  seen  her  since,  but  have  heard  through  her 
family  that  she  was  delivered  of  a  healthy  child  after  a  somewhat 
tedious  labor. 

Cervical  Endometritis  in  an  Imperfectly  Developed  Uterus. — This 
lady  appeared  to  be  rather  frail,  but  had  always  enjoyed  good  health. 
She  beffan  to  menstruate  first  at  thirteen,  and  for  the  first  vear  was 
rather  irregular,  and  always  had  some  pain  the  first  day.  The  flow 
lasted  only  from  two  to  three  days,  and  the  dysmenorrhoea  increased 
somewhat  from  month  to  month ;  and  she  began  to  have  backache 
before  and  after  menstruation,  with  occasional  leucorrhoea.  When  she 
was  twenty-four  years  old  she  was  married,  but  from  that  time  onward 
her  dysmenorrliGea  increased  ;  she  had  almost  continuous  backache, 
and  a  good  deal  of  tenesmus,  with  occasional  attacks  of  frequent 
urination.  One  year  after  her  marriage  she  came  under  my  observa- 
tion, and  I  found  the  uterus  rather  below  the  normal  size  ;  there  was 
slight  anteflexion  of  the  cervix,  but  the  body  of  the  uterus  was  in  its 
normal  position.  The  uterus  was  tender  to  the  touch,  and  there  was 
also  some  hyperaesthesia  of  the  vagina.     A  speculum  examination 


INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS.  203 

revealed  a  general  congestion  of  the  cervix  and  vagina,  the  cervix 
being  smaller  than  it  ought  to  be ;  the  os  externum  was  small,  and 
while  there  was  a  slight  vaginal  leucorrhoea  there  was  no  discharge 
from  the  cervix.  The  canal  of  the  cervix  was  quite  large  in  jDropor- 
tion  to  the  size  of  the  external  os,  and  the  os  internum  was  so  small  that 
an  ordinary-sized  uterine  sound  was  passed  with  difhculty,  and  caused 
pain.  The  canal  of  the  cervix  contained  a  plug  of  very  thick,  dark- 
colored,  and  very  tenacious  secretion.  This  was  removed  with  the 
curette,  but  with  great  difficulty,  and  quite  a  free  haemorrhage  oc- 
curred during  its  removal.  After  removing  this  secretion  very  care- 
fully, and  waiting  until  all  haemorrhage  had  subsided,  a  mixture  of 
carbolic  acid,  glycerin,  and  water  was  carefully  applied  to  the  entire 
canal  for  the  purj)ose  of  neutralizing  any  septic  material  which  might 
exist  there.  A  small  V-shaped  piece  was  removed  from  each  side 
of  the  cervix  at  the  os  externum,  and  four  very  superficial  incis- 
ions were  made  at  the  os  internum.  The  uterine  dilator  was  then 
introduced,  and  the  os  internum  and  externum  dilated  until  a  No.  9 
sound  could  be  easily  introduced.  The  patient  was  kept  quiet  in  bed 
for  several  days,  and  as  there  was  no  constitutional  or  local  disturbance 
at  the  end  of  that  time  she  was  allowed  to  get  up  and  go  about  again. 
From  this  time  onward  for  about  three  months  the  uterine  sound 
was  passed  once  a  week  to  prevent  contraction  of  the  cervical  canal. 
At  the  same  time  the  secretion  was  carefully  removed  from  the  ca- 
nal, and  carbolic  acid  and  tincture  of  iodine — one  part  of  the  former 
to  two  of  the  latter — were  thoroughly  applied.  A  vaginal  injection 
was  ordered  of  one  quart  of  warm  water  and  forty  grains  of  sulphate 
of  zinc,  to  be  used  once  a  day.  The  effect  of  this  treatment  was  to 
relieve  the  dysmenorrhoea,  backache,  and  general  feeling  of  discom- 
fort in  the  pelvis. 

The  leucorrhoeal  discharge  became  more  free,  somewhat  lighter  in 
color,  and  less  tenacious.  The  application  of  iodine  and  carbolic  acid 
was  continued  for  two  months  longer,  when  all  treatment  was  sus- 
pended for  three  months.  At  the  end  of  that  time  she  returned, 
and  stated  that  her  leucorrhoea  remained  the  same,  although  other- 
wise she  felt  tolerably  well.  In  passing  the  sound  the  canal  of  the 
cervix  was  found  to  be  ample,  but  the  character  of  the  secretion  had 
returned  to  what  it  was  when  she  first  came  under  my  observation. 
I  made  applications  of  the  tincture  of  iodine  to  the  cervical  canal 
for  about  two  months,  without  apparently  improving  the  condition ; 
I  then  tried  a  10-per-cent  solution  of  chloride  of  zinc,  applying  it 
once  a  week,  but  without  improving  the  case.  I  then  decided  to 
remove  a  longitudinal  strip  from  each  side  of  the  mucous  membrane 


204  DISEASES  OF  WOMEN. 

of  the  cervical  canal ;  this  was  accomplished  by  seizing  the  cervix 
with  a  tenaculum,  and  then  passing  a  small-sized  Sims's  curette 
(Fig.  102)  up  to  the  internal  os,  and  under  strong  pressure  draw- 
ing it  down  and  cutting  out  a  deep  strip  of  the  mucous  membrane. 


Fig,  102. — Sims's  curette. 


This  was  repeated  on  the  opposite  side.  The  idea  of  removing  the 
two  sections  rather  than  removing  the  entire  membrane,  as  recom- 
mended by  Sims,  Thomas,  and  others,  was  to  leave  a  portion  of  the 
membrane,  which  would  expand  as  healing  took  place,  and  in  that 
way  compensate  for  the  loss  of  tissue,  and  thereby  prevent  the  oc- 
currence of  stricture  of  the  canal  by  contraction.  During  the  heal- 
ing process  the  uterine  sound  was  cautiously  passed  about  every  third 
day.  This  at  first  caused  some  haemorrhage  and  pain,  but  soon  it 
could  be  done  without  trouble  of  either  kind  resulting  from  it.  The 
applications  of  iodine  were  again  begun  and  continued  for  about 
two  months,  six  applications  in  all  being  made.  The  final  effect 
of  this  was  to  control  the  leucorrhoea,  and  the  little  discharge  that 
remained  became  more  transparent  and  less  tenacious — more  like 
the  normal  secretion  of  the  Nabothian  glands.  She  was  then  dis- 
missed apparently  well,  and  she  remained  so,  but  continued  to  be 
sterile. 

I  have  treated  a  large  number  of  cases  of  this  class  in  the  same 
way,  except  that  I  have  not  lost  time  in  trying  different  applications, 
but  have  removed  the  sections  of  the  mucous  membrane  at  the  out- 
set. Two  of  my  patients  have  subsequently  borne  children  ;  several 
of  them  have  had  some  contraction  of  the  canal,  which  had  to  be 
relieved  by  dilatation.  In  quite  a  number  of  them  the  leucorrhoea 
has  returned,  and  while  I  have  been  able  to  keep  them  comfortable 
by  occasional  treatment,  they  have  never  completely  recovered. 

Cervical  Endometritis  in  a  Young  Girl,  with  Marked  Thickening 
of  the  Mucous  Membrane  of  the  Cervix,  Dilatation  of  the  External  Os, 
and  Eversion  of  the  Mucous  Membrane. — This  girl  was  rather  small, 
delicate,  of  marked  nervous  temperament,  and  highly  cultivated. 
Her  circumstances  were  such  that  she  had  been  able  to  obtain  an 
excellent  education  and  every  advantage  and  accomplishment  that 
she  could  desire.  She  was  precocious,  and  began  to  menstruate 
when  she  was  eleven  and  a  half  years  old.  She  had  always  suffered 
slight  pain  during  her  menses,  and  also  had  leucorrhaa,  which  was 
trivial  at  first.  She  had  suffered  much  from  backache,  headache, 
and  general  debility,  but  was  able  to  attend  to  her  education  until 


INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS.  205' 

she  was  sixteen  years  old.  Her  leucorrboea  at  that  time  became 
quite  profuse,  and  her  backache  and  pelvic  tenesmus  so  severe  that 
she  was  obliged  to  give  up  muscular  exercise  almost  altogether. 
During  this  time  she  had  been  treated  with  tonics,  and  change  of  air. 
At  the  age  of  eighteen  she  was  placed  under  the  care  of  a  physician 
in  New  York,  who  said  that  she  had  some  falling  of  the  womb,  and 
treated  her  by  tamponing  the  vagina  with  cotton,  after  the  method 
of  Boseman,  who,  I  believe,  calls  this  method  of  treatment  "  column- 
ing  the  vagina." 

She  derived  no  benefit  from  this,  although  it  was  continued  for 
several  months.  In  fact,  she  became  much  worse.  She  was  then 
placed  under  my  care,  when  she  was  nineteen  years  of  age ;  her 
general  condition  at  that  time  was  one  of  marked  neurasthenia.  Her 
extremities  were  cold  and  clammy,  her  pulse  was  feeble  and  rapid ; 
her  pupils  were  widely  dilated,  and,  while  she  was  naturally  of  a 
pleasant  and  happy  disposition,  she  became  apprehensive  of  trouble, 
and  spent  most  of  her  time  in  thinking  and  talking  about  her 
symptoms.  Some  times  she  was  dull  and  sleepy,  at  other  times 
wakeful  and  sleepless ;  her  appetite  was  capricious — at  times  good, 
and  at  other  times  poor ;  her  bowels  were  constipated  ;  she  was  quite 
emotional,  and  easily  affected  to  tears  by  either  pleasant  or  unpleasant 
mental  impressions. 

The  uterus  was  found  in  its  normal  position,  its  body  normal  in 
size  and  shape,  and  not  especially  tender ;  the  ovaries  were  tender ; 
the  cervix  was  quite  enlarged,  and  to  the  touch  gave  the  usual  phys- 
ical signs  of  a  cervix  that  has  sustained  a  bilateral  laceration  super- 
ficially, or  sufiicient  to  give  rise  to  ectropion,  as  it  is  now  called. 

The  vagina  and  vulva  were  quite  relaxed,  due,  I  presume,  to  the 
long-continued  use  of  the  tampon  ;  at  least,  I  know  of  no  other  rea- 
son for  this  condition,  although  she  was  evidently  of  an  amorous 
disposition,  and  no  doubt  suffered  from  physiological  congestion  of 
the  sexual  organs.  I  have  no  reason  to  believe  that  she  had  ever 
abused  herself  or  been  abused,  unless  this  tamponing  treatment  under 
the  circumstances  may  be  called  abuse. 

The  speculum  revealed  a  large  cervix,  looking  quite  like  that  of 
a  woman  who  had  borne  children.  There  was  well-marked  eversion 
which  brought  into  view  anteriorly  and  posteriorly  about  half  an 
inch  of  the  cervical  mucous  membrane,  which  was  easily  recognized 
as  such  by  its  rugous  arrangement,  and  the  presence  of  the  Na- 
bothian  glands,  which,  though  they  could  not  be  seen,  were  proved 
to  be  present  at  that  point  by  the  secretion  which  was  freely  poured 
out  on  the  exposed  surface. 


206  DISEASES  OF  WOMEN. 

The  most  careful  examination  failed  to  find  any  injury  of  the 
muscular  walls  of  the  cervix  showing  that  the  case  was  one  of  ever- 
sion  of  the  cervical  mucous  membrane.  This  patient  entered  my 
private  institution,  and  was  treated  generally  by  rest,  massage,  baths, 
and  careful  attention  on  the  part  of  the  nurse,  with  a  view  to  im- 
proving her  mental  condition  by  diverting  her  mind  from  herself, 
and  fully  occupying  her  time  with  the  treatment.  The  bowels  were 
kept  regular  with  a  laxative  pill ;  sleep  was  secured  by  a  dose  of 
bromide  in  the  afternoon,  and  another  at  bed-time  when  necessary  ; 
and  one  ninetieth  of  a  grain  of  the  hydrobromide  of  hyoscine  was 
given  three  times  a  day,  with  the  effect  of  improving  her  nervous 
system.  A  vaginal  douche  was  given  once  a  day,  consisting  of  sixty 
grains  of  sulphate  of  zinc  to  a  quart  of  warm  water.  This  had  the 
eifect  of  overcoming  the  vaginal  relaxation  after  a  time.  Three 
weeks  after  she  came  under  my  care  her  general  health  had  improved 
noticeably,  and  she  passed  through  her  menstrual  period  with  less 
pain.  I  then  removed  the  everted  portion  of  the  mucous  membrane, 
being  careful  not  to  make  the  exsection  entirely  circumscribe  the 
OS  externum.  (Jn  the  sides,  where  the  eversion  was  less  marked, 
portions  of  the  membrane  were  left  untouched.  This  was  done  to 
avoid  stricture,  which  I  presumed  might  occur  after  healing.  The 
exsection  was  made  with  the  scissors,  and  though  there  was  consid- 
erable htemorrhage,  this  was  controlled  by  the  application  of  pledgets 
of  cotton  dipped  in  chloride  of  iron,  and  kept  in  place  by  tampon- 
ing. When  the  tampon  was  removed  the  douche  of  zinc  solution 
was  resumed,  and  once  a  week  thereafter  iodine  and  carbolic  acid 
were  applied  to  the  cervical  canal.  As  the  healing  progressed  the 
external  os  contracted,  and  the  caliber  of  the  canal  diminished  ;  the 
leucorrhceal  discharge  also  subsided,  and  at  the  end  of  three  months 
the  local  trouble  had  entirely  disappeared,  and  the  cervix  looked  like 
a  virgin  cervix,  except  that  the  os  was  somewhat  larger  and  oblong 
instead  of  circular.  Her  general  health  greatly  improved,  and  she 
was  soon  able  to  take  gymnastic  exercise  and  cold  baths,  and  to  walk 
and  ride  in  the  open  air. 

She  was  dismissed  quite  well,  and  has  remained  so. 


CHAPTER  X. 

COI?POKEAL    END0METKITI8. 

The  most  conflicting  views  are  to  be  found  in  the  literature  of 
medicine  regarding  the  relative  frequency  of  corporeal  and  cervical 
endometritis.  Much  of  this  division  of  opinion  comes,  no  doubt, 
from  imperfect  knowledge  regarding  the  diagnosis  of  corporeal  endo- 
metritis. 

The  facts  appear  to  be  as  follows :  Tliat  corporeal  endometritis  is 
not  so  often  seen  as  cervical ;  that  either  may  occur  alone ;  that  they 
may  occur  together ;  and  that  corporeal  endometritis  alone  is  most 
rare  of  all.  These  facts  have  been  obtained  from  long- continued 
observation  in  a  very  large  field,  and  I  feel  confident  of  accuracy  in 
the  facts,  because  I  have  given  due  attention  to  the  means  and 
methods  of  diagnosis — the  only  way  to  arrive  at  correct  conclusions. 

There  is  another  cause  of  confusion  on  this  subject  growing  out 
of  imperfect  methods  of  investigation,  and  that  is,  classing  under  the 
head  of  endometritis  some  widely-differing  pathological  conditions, 
such,  for  example,  as  the  changes  in  the  tissues  following  the  acute 
puerperal  affections  of  the  uterus. 

It  will  be  seen  by  what  follows  that,  although  the  diagnosis  of 
endometritis  is  difiicult,  careful  attention  to  that  part  of  the  subject 
will  secure  a  degree  of  accuracy  which  has  not  been  heretofore  gen- 
erally attained. 

Pathology. — The  pathology  of  corporeal  endometritis  is  doubt- 
less the  same  in  character  as  that  of  cervacal  endometritis,  but  un- 
fortunately there  are  not  the  same  opportunities  of  observing  the 
changes  which  take  place  in  the  mucous  membrane  as  in  the  cervi- 
cal form.  On  this  account  post-mortem  examinations  are  the  chief 
sources  of  knowledge  of  the  pathology,  and  as  this  disease  is  never 
fatal  an  opportunity  of  examining  the  uterus  only  occurs  when 
patients  with  endometritis  die  of  some  other  affection,  hence  the 
inexact  knowledge  on  this  subject. 

807 


208  DISEASES  OF  WOMEN. 

There  is  also  a  marked  liability  to  error  in  post-mortem  investi- 
gations of  the  endometrium.  In  constitutional  diseases,  which  prove 
fatal,  there  are  certain  changes  in  the  mucous  membrane  of  the  ute- 
rus which  resemble  those  of  endometritis,  yet  they  are  not  exactly 
the  same,  and  do  not  represent  the  anatomical  lesions  of  uncompli- 
cated endometritis,  and  should  not  be  taken  for  such. 

The  facts  regarding  the  pathology  of  corporeal  endometritis  which 
appear  quite  deiinitely  settled  are  as  follows  :  In  some  cases  there  is 
a  general  congestion  and  thickening  of  the  entire  membrane,  the 
lesions  of  vascularity  extending  to  the  glands  of  the  uterus.  This 
gives  rise  to  increased  nutritive  activity  on  the  part  of  these  glands, 
and  hypersecretion.  I  am  not  at  all  satisfied,  however,  that  the  dis- 
charge from  these  glands  is  exactly  the  same  as  it  is  from  the  cervix. 
I  am  inclined  to  think  that  it  is  more  serous,  less  tenacious,  and  more 
frequently  contains  blood  than  that  from  the  cervical  glands.  The 
whole  mucous  membrane  may  be  denuded  of  its  epithelium,  or  it 
may  be  so  only  in  parts ;  and,  again,  the  congestion  appears  to  be 
greater  in  spots,  and  in  these  places  there  is  thickening  of  the  mem- 
brane. These  thickened  red  patches  are  generally  found  at  the 
mouths  of  the  glands.  Not  infrequently  there  are  proliferations  of 
the  mucous  membranes,  polypoid  in  character — a  condition  which  is 
sometimes  called  "  endometritis  polyposa."  This  new  product  is  one 
of  the  most  common  results  of  endometritis  of  long  standing. 

Sometimes  the  walls  of  the  uterus  are  found  thickened  so  that 
the  whole  uterus,  as  well  as  its  cavity,  is  enlarged.  In  other  cases 
the  walls  of  the  uterus  have  been  found  diminished  in  thickness, 
and  changed  in  structure  by  fatty  degeneration.  These  changes 
in  the  walls  of  the  uterus  may  or  may  not  be  due  to  the  endo- 
metritis. 

Corporeal  endometritis  belongs  to  that  class  of  inflammations  in 
which  the  process  does  not  pass  through  its  various  stages,  and  then 
end  in  recovery,  with  or  without  permanent  changes  of  structure. 
In  this  it  differs  from  acute  inflammations,  which  begin  and  run 
through  all  their  stages,  and  end  in  recovery. 

If  once  well  established,  the  inflammation  shows  very  little  tend- 
ency to  recover  without  treatment ;  hence  it  is  that  the  cases  are 
often  found  that  begin  in  early  life,  and  continue  up  to  the  meno- 
pause. There  is  very  little  tendency  in  the  natural  history  of  these 
affections  to  become  worse  or  change  their  character ;  they  often  re- 
main the  same,  excepting  that  the  constitutional  disturbance  may 
increase,  and  the  patient  fail  in  general  health. 

Symptomatology. — Owing  to  the  fact  that  the  diagnosis  of  cor- 


CORPOREAL  ENDOMETRITIS.  209 

poreal  endometritis  is  difficult,  it  is  very  necessary  to  give  close  atten- 
tion to  the  evidence  presented. 

The  symptoms  of  this  affection  are  well  marked,  and,  although 
not  diagnostic,  they  are  of  great  value  when  taken  in  connection 
with  the  physical  signs.  They  naturally  arrange  themselves  into 
two  classes — constitutional  and  local. 

The  constitutional  symptoms  are  manifested  by  the  nervous  sys- 
tem and  digestive  organs.  There  is  frequently  capricious  appetite, 
flatulence,  and  constipation.  The  derangement  of  the  stomach  is 
irregular,  often  varying  in  a  day,  showing  that  it  is  a  reflex  nervous 
disturbance,  not  unlike  that  which  occurs  in  gestation.  Tlie  mam- 
mary glands  are  often  sympathetically  affected,  becoming  enlarged 
and  tender,  and  the  areola  takes  on  a  darker  color.  These  symp- 
toms, taken  in  the  aggregate,  resemble  very  closely  those  found  in 
spurious  pregnancy,  excepting  that  the  mental  obliquity  is  absent. 
It  will  be  seen  that  the  symptoms,  including  the  derangement  of  the 
digestive  organs,  are  all  such  as  might  be  expected  from  reflex  nerv- 
ous derangement,  and  such,  no  doubt,  is  their  explanation. 

I  am  aware  that  the  symptoms  here  given  have  all  been  said  to 
occur  in  cervical  endometritis,  but,  while  there  may  be  some  slight 
constitutional  disturbance  from  this  affection,  it  is  never  so  well  de- 
fined as  in  corporeal  endometritis. 

Symptoms  referable  to  the  general  nervous  system,  which  occur 
in  this  affection,  are  not  diagnostic,  yet  they  are  valuable  when  taken 
in  connection  with  the  rest  of  the  history. 

Headache,  sleeplessness,  mental  depression,  and  pains  in  the  spi- 
nal cord,  are  often  present,  but  I  know  of  no  special  nerve  symptoms 
peculiar  to  corporeal  endometritis.  Among  the  local  symptoms  the 
most  important,  b}^  far,  is  derangement  of  the  menstrual  function. 
This  I  consider  the  symptom  by  which  the  differential  diagnosis  be- 
tween cervical  and  corporeal  endometritis  can  be  made,  and  therefore 
it  should  be  borne  in  mind  at  all  times. 

One  would  naturally  expect  that  in  inflammation  of  the  corporeal 
endometrium  the  function  of  the  membrane  would  certainly  be  de- 
ranged, and  such  is  the  fact.  The  catamenial  discharge  may  be  pro- 
fuse, scanty,  irregular,  and  attended  with  pain,  or  the  function  may 
be  suppressed  altogether ;  the  rule  is,  however,  that  profuse,  pro- 
longed, and  painful  menstruation  is  present.  When  either  of  these 
menstrual  derangements  occurs,  and  there  is  no  constitutional  or  other 
local  cause  to  account  for  it,  we  may  reasonably  infer  that  the  mu- 
cous membrane  of  the  uterus  is  at  fault. 

It  may  appear  strange  that  opposite  conditions,  like  menorrhagia 
15 


210  DISEASES  OF  WOMEN. 

and  amenorrhoea,  sliould  occur  in  the  same  affection ;  but  this  is  ac- 
counted for  by  the  condition  of  the  mucous  membrane  in  the  differ- 
ent stages  of  the  disease.  The  same  peculiarities  of  behavior  are 
noticed  in  inflammation  of  other  mucous  membranes ;  for  example, 
in  bronchitis  the  membrane  at  first  may  be  unduly  dry,  and  at  an- 
other stage  of  the  disease  there  may  be  a  profuse  secretion.  In  ad- 
dition to  these  changes,  in  the  menstrual  function  there  usually  is 
marked  backache,  not  different  in  character,  but  being  more  severe 
than  in  cervical  affections.  There  is  also  more  pain  in  the  uterus, 
pelvic  tenesmus,  vesical  and  rectal  irritation.  Leucorrhoea  is  a 
marked  symptom  also.  The  character  of  the  discharge,  as  already 
noticed,  is  more  serous,  less  tenacious,  and  more  frequently  contains 
a  few  blood-  and  pus-corpuscles.  When  cervical  and  corporeal  endo- 
metritis occur  together,  the  discharge  shows  the  characteristics  of 
both  affections. 

Physical  Signs. — The  physical  signs  of  endometritis  are  the 
same  in  character  as  those  indicative  of  inflammation  elsewhere. 
There  is  tenderness  detected  by  the  bimanual  touch,  which  usually 
shows  that  the  body  of  the  organ  is  sensitive.  After  thoroughly 
cleansing  the  vagina  with  a  douche,  a  small  tampon  of  cotton  should 
be  placed  against  the  cervix  and  allowed  to  remain  for  two  or  three 
hours.  If  pus  is  found  on  the  cotton,  it  is  a  valuable  sign  of  cor- 
poreal endometritis.  By  the  use  of  the  sound,  four  indications  of 
the  disease  can  be  obtained.  First,  the  abnormal  tenderness ;  second, 
the  enlargement  of  the  uterine  cavity,  as  detected  by  actual  meas- 
urement ;  third,  dilatation  of  the  os  externum  ;  and,  finally,  the 
great  vascularity  of  the  membrane,  as  shown  by  bleeding  on 
touch. 

In  using  the  sound  for  diagnostic  purposes  in  corporeal  endome- 
tritis, much  skill  and  practice  are  necessary  in  order  to  make  the  ex- 
amination with  advantage  to  the  diagnostician  and  safety  to  the 
patient.  Moreover,  care  should  be  taken  to  make  a  disinfectant  ap- 
plication before  using  the  sound,  and  to  be  sure  that  the  sound  itself 
is  thoroughly  aseptic.  Many  of  tho  difficulties  following  the  use  of 
the  sound,  related  in  the  books,  I  believe  to  be  due  to  lack  of  care 
and  attention  to  these  points,  thus  permitting  the  carrying  of  septic 
material  into  the  uterus. 

The  density  of  the  uterine  tissues  is  a  valuable  sign  in  determin- 
ing the  existence  of  endometritis.  As  a  nde,  the  body  of  the  uterus 
is  less  dense  than  normal,  excepting  in  cases  of  long  standing,  in 
which  there  is  sometimes  induration  or  hardening  of  the  uterus. 

Prognosis. — Corporeal  endometritis  is  more  difficult  to  manage 


CORPOREAL  ENDOMETRITIS.  211 

than  cervical,  and  hence  this  has  led  many  of  the  writers  in  the  past 
to  state  that  the  affection  is  incurable  in  many  cases.  At  the  pres- 
ent time  I  believe  that  a  more  favorable  view  of  the  matter  may  be 
taken.  The  disease  in  itself  is  not  dangerous  to  life,  and,  when  un- 
complicated, will  usually  yield  to  appropriate  treatment.  There  is 
a  decided  tendency  in  many  cases  for  it  to  return,  but  even  then  it 
can  be  relieved  by  removing  the  cause.  Recovery  takes  place  at  the 
menopause  or  senile  endometritis  follows. 

The  affection  is  not  in  itself  self-limited,  but  is  limited  by  the 
period  of  functional  activity  of  the  uterus.  There  is  a  prevailing 
opinion  that  endometritis,  when  it  continues  up  to  the  menopause, 
complicates  "  the  change  of  life,"  and  favors  the  development  of 
malignant  disease.     The  former  opinion  is  true,  the  latter  doubtful. 

The  results  vary  with  the  different  kinds  of  treatment  used.  I 
have  never  seen  a  case  cured  by  certain  methods,  which  have  been 
commended  to  the  exclusion  of  all  others ;  for  example,  hot-water 
douching,  and  the  application  of  the  tincture  of  iodine  to  the 
vagina. 

]^either  does  endometritis  yield  to  treatment  so  long  as  there  is 
a  displacement  of  the  uterus,  or  a  laceration  of  the  cervix ;  but,  when 
all  the  conditions  necessary  to  recovery  are  secured,  then  endometritis 
will  yield  to  local  treatment  in  the  vast  majority  of  cases. 

Causation. — The  causes  of  corporeal  endometritis  have  been  re- 
ferred to  in  discussing  cervical  endometritis ;  hence,  to  save  repe- 
tition, it  will  suffice  to  say  that  there  are  certain  conditions  oi  the 
general  system  which  predispose  to  the  affection.  The  strumous 
diathesis,  imperfect  general  nutrition  from  either  gross  living  and 
sedentary  habits,  or  exhaustion  from  overtaxation,  are  the  chief  pre- 
disposing conditions. 

The  direct  or  exciting  causes  are  complicated  labors,  miscarriages, 
derangement  of  menstruation,  and  sepsis. 

The  vast  majority  of  cases  of  corporeal  endometritis,  which  have 
come  under  my  observation,  were  clearly  due  to  the  causes  given 
above.  In  fact,  if  those  caused  by  gonorrhoea  are  excluded,  nearly 
all  the  others  can  be  ascribed  to  lesions  of  parturition  and  derange- 
ment of  menstruation,  which  arrest  the  post-partum  and  post-men- 
strual involution. 

Treatment. — The  constitutional  treatment  of  inflammatory  dis- 
eases of  the  uterus  was  briefly  referred  to  while  discussing  the  treat- 
ment of  cervical  endometritis,  so  that  it  is  only  necessary  to  repeat 
the  general  statement,  that  every  means  should  be  employed  to  re- 
store the  general  health.    The  treatment  must,  as  a  matter  of  coursCi 


212  DISEASES  OF   WOMEN. 

be  adapted  to  the  nature  and  degree  of  tlie  impaired  state  of  the 
general  organization  in  the  given  case. 

The  local  treatment,  such  as  the  hot-water  douche,  already  de- 
scribed, apph'es  in  part  to  cervical  endometritis,  and  therefore  need 
not  be  repeated  here.  It  will  suffice  to  give  directions  regarding 
topical  applications  to  the  corporeal  mucous  membrane. 

I  will  first  consider  the  indications  for  intra-uterine  medication, 
the  remedies  to  be  used,  and  the  means  of  employing  them.  This 
question  is  still  with  many  an  unsettled  one,  both  as  regards  the 
curability  of  corporeal  endometritis,  and  the  value  and  safety  of 
intra-uterine  medication.  The  literature  on  the  subject  of  intra- 
uterine treatment  is  not  very  definite,  hence  I  shall  confine  myself 
to  a  few  points,  which  I  regard  as  fairly  well  established,  and  likely 
to  be  of  service  in  the  treatment  of  this  disease. 

The  important  questions  which  come  up  for  consideration  on  this 
subject  are,  first,  is  it  safe  and  advantageous  to  make  intra-uterine 
applications  ?  Second,  if  so,  what  curative  agents  shall  be  employed ; 
and,  third,  how  shall  they  be  applied  ? 

Turning  to  the  text-books  or  the  current  literature  on  the  sub- 
ject in  search  of  an  answer  to  the  first  question,  I  find  the  greatest 
diversity  of  opinions. 

The  pioneer  gynecologists  of  Europe,  such  as  M.  Gendrin,  M. 
Jobert  de  Lamballe,  Bennet,  and  Simpson,  rarely,  if  ever,  made  ap- 
plications beyond  the  os  internum,  believing  that  endometritis  could 
be  cured  by  treating  the  cervix  and  the  cervical  canal.  On  the  other 
hand,  we  find  that  Aran,  Scanzoni,  and  Gantillon,  and  Dr.  Henry 
Miller  (who,  by  the  way,  was  the  first  to  employ  intra-uterine  medi- 
cation in  this  country),  Kammerer,  Nott,  Peaslee,  and  many  others, 
relied  to  a  very  great  extent  on  intra-uterine  applications  for  the 
relief  of  corporeal  endometritis. 

Many  more  names  might  be  mentioned  to  show  the  want  of  har- 
mony among  physicians  on  this  point,  but  no  useful  knowledge 
would  be  gained  thereby.  All  that  can  be  learned  from  a  review  of 
the  Uterature  is  that  intra-uterine  medication  is  more  extensively 
employed  now  than  formerly.  Believing  that  time  tends  to  drift 
the  profession  to  the  side  of  correct  therapeutics,  it  may  be  inferred 
that  local  applications  to  a  part  or  to  the  whole  of  the  lining  mem- 
brane of  the  uterine  cavity  are  sometimes  necessary,  if  not  indispen- 
sable, in  treating  endometritis. 

In  seeking  an  answer  to  the  second  question,  one  encounters  a 
variety  of  medicinal  agents,  ranging  from  the  actual  cautery  to  the 
blandest  anodynes. 


CORPOREAL  ENDOMETRITIS.  213 

Bearing  in  mind,  however,  the  second  object  to  be  gained,  name- 
ly, to  restore  the  organ  to  health,  and  leave  it  uninjured,  it  is  evident 
that  all  destructive  agents  should  be  avoided. 

This  has  already  been  stated  in  discussing  the  treatment  of  cer- 
vical endometritis,  and  all  that  was  then  said  applies  with  greater 
force  in  regard  to  corporeal  endometritis,  because  that  portion  of  the 
mucous  membrane  is  more  delicate  in  structure. 

In  my  own  practice  I  employ  either  bichloride  of  mercury,  one 
grain  to  an  ounce  of  water ;  tincture  of  iodine ;  tincture  of  iodine, 
two  parts,  and  carbolic  acid,  one  part ;  or  suppositories  of  iodoform 
and  cocoa-butter. 

There  is  so  much  risk  in  treating  the  mucous  membrane  of  the 
cavity  of  the  body  of  the  uterus  that  there  are  certain  precautions 
which  should  be  kept  in  mind.  These  may  be  formulated  as  fol- 
lows :  Tliat  intra-uterine  applications,  excepting  to  the  cervical  canal, 
should  not  be  used  until  other  means  have  been  thoroughly  tried 
and  have  failed.  The  uterus  should  be  in  or  near  its  normal  posi- 
tion. The  cervix  uteri  should  be  sufficiently  dilated  to  allow  any 
excess  of  the  fluid  to  escape  from  the  cavity  of  the  body. 

After  having  carefully  freed  the  cervical  canal  from  the  secretion, 
the  easiest  and  most  effectual  way  of  making  applications  is  to  use 
the  glass  pipette,  already  described. 

The  solution  to  be  employed  is  drawn  up  into  the  glass  tube  by 
the  rubber  bulb ;  the  instrument  is  then  passed  up  to  the  os  inter- 
num or  to  the  fundus  uteri,  if  desired,  and,  as  it  is  withdrawn,  press- 
ure is  to  be  made  upon  the  bulb  which  forces  out  the  solution  and 
brings  it  in  contact  with  the  entire  lining  of  the  canal. 

The  method  generally  in  use  of  dipping  a  probe  wrapped  with 
cotton  into  the  solution,  and  passing  that  up  into  the  canal,  is  very 
unsatisfactory.  The  cotton  on  the  probe  injures  the  mucous  mem- 
brane, and  the  solution  is  deposited  about  the  os  externum — very 
little,  if  any,  getting  into  the  canal. 

The  injections  by  means  of  a  syringe  and  a  reflux  catheter,  com- 
mended by  many,  I  have  tried,  but  I  have  abandoned  the  method 
because  it  is  dangerous  and  unnecessary. 

It  is  well  to  use  some  bland  fluid,  such  as  warm  water  and  salt, 
to  test  the  toleration  of  the  uterus  before  using  the  more  potential 
agents.  A  small  quantity  of  the  agent  used  is  all  that  is  necessary. 
Six  to  ten  drops  is  sufficient  to  cover  the  surface  to  be  treated,  and 
more  than  that  is  useless. 

When  from  long-continued  congestion  the  mucous  membrane  of 
the  cavity  of  the  uterus  has  become  hypertrophied,  giving  rise  to 


214  DISEASES  OP  WOMEN. 

that  condition  now  known  as  endometritis  polyposa,  the  use  of  the 
curette  gives  the  most  prompt  rehef.  The  blunt  instrument  should 
always  be  used,  because  it  is  perfectly  eflEective  and  free  from 
danger. 

Method  of  Curetting. — The  pathological  conditions  which  demand 
the  use  of  the  curette  have  already  been  referred  to.  The  instru- 
ment which  I  employ  has  also  been  described,  and  the  advantages 
which  I  consider  that  it  possesses  have  been  clearly  pointed  out. 
There  is  still  something  to  be  said  regarding  the  method  of  using  it. 
Dilatation  of  the  cervical  canal  should  be  made  rapidly,  under  anaes- 
thesia, with  Goodell's  dilator.  This  method  of  immediate  dilatation 
is  greatly  in  advance  of  the  old  way  of  dilating  by  sponge  or  sea- 
tangle  tents,  which  always  caused  great  pain,  and  sometimes  inflam- 
mation and  septic  infection. 

The  patient  is  placed  in  Sims's  position  and  the  cervix  caught 
and  held  with  a  tenaculum  curved  on  the  flat  (see  Fig.  6)  and  the 
cervix  dilated.  The  curette  is  then  curved  so  that  it  will  pass 
into  the  uterus  and  to  one  side,  and,  while  the  to-and-fro  motion 
is  being  made,  the  instrument  is  also  moved  slowly  toward  the  op- 
posite side.  I  find  that,  Mdth  my  curette,  fungosities  or  decidua 
can  be  pushed  off  or  detached  with  the  upward  as  well  as  with  the 
downward  or  scraping  motion.  When  the  anterior  wall  has  been 
thoroughly  treated,  the  instrument  is  withdrawn  into  the  cervix, 
bent  a  little  in  the  opposite  direction,  and  turned  around  so  that  it 
will  face  the  posterior  wall,  which  is  then  treated  in  the  same  man- 
ner as  was  the  anterior.  From  a  large  experience  I  have  come  to 
look  upon  this  operation  as  one  of  the  safest  in  gynecology,  and  very 
satisfactory  in  its  results.  Of  course,  the  usual  surgical  cleanliness 
should  be  observed,  and  the  uterus  should  be  washed  out  with  an 
antiseptic  solution  and  packed  with  gauze. 

ILLUSTRATIVE    CASES. 

The  patient  was  thirty-two  years  of  age,  who  had  been  married 
ten  years,  and  had  given  birth  to  two  children.  She  made  a 
slow  recovery  from  her  last  confinement,  and  nursed  her  child  for 
about  six  months.  Her  health  then  began  to  fail,  and  the  child  was 
weaned. 

Two  months  after  this  the  menses  returned,  and  at  the  time 
were  quite  scanty  and  only  lasted  for  a  day  or  two.  After  this  she 
suffered  from  backache,  pelvic  tenesmus,  and  irritable  bladder, 
with  free  leucorrhoea,  at  first  like  an  ordinary  cervical  secretion  in 
character.     Her  general  condition  also  became  disordered.      The 


CORPOREAL  ENDOMETRITIS.  215 

appetite  was  capricious  ;  the  bowels  constipated,  and  distended  from 
flatulence.  She  also  liad  occasional  attacks  of  nausea,  and  at  times 
headache  ;  she  became  quite  nervous,  and  her  sleep  was  broken. 
Her  menstruation  became  irregular,  generally  coming  on  at  the  end 
of  two  or  three  weeks  and  continuing  longer  than  normal,  and  was 
too  free.  When  Jirst  examined  I  found  the  uterus  large,  the  in- 
crease in  size  being  mostly  of  the  body  and  fundus.  Bimanual 
pressure  being  made  upon  the  body  of  the  uterus  gave  rise  to  a  dull 
pain.  A  speculum  examination  revealed  considerable  redness  around 
the  OS  externum.  The  discharge,  as  seen  coming  from  the  canal, 
was  dark  in  color,  as  if  stained  and  streaked  with  blood  ;  around 
this  tenacious  material  there  was  a  little  sero-purulent  discharge 
noticeable.  The  sound  entered  two  and  a  half  inches,  and  could  be 
moved  about  considerably  in  the  cavity  of  the  body,  showing  that 
the  cavity  was  enlarged.  Gently  touching  the  fundus  and  sides  of 
the  uterus  with  the  sound  gave  rise  to  pain,  and  the  patient  com- 
plained of  a  little  nausea  and  faintness.  From  the  general  history 
and  the  physical  signs  the  diagnosis  of  inflammation,  involving  the 
entire  mucous  membrane  of  the  uterus,  was  made. 

The  subsequent  history  fully  corroborated  the  diagnosis  in  every 
respect.  At  this  time  the  patient's  tongue  was  coated,  her  appetite 
poor,  atid  she  was  constipated.  A  dose  of  blue  mass  with  a  grain 
of  ipecac  was  given  at  night,  followed  by  a  Seidlitz  powder  in  the 
morning ;  and  after  this  a  bitter  tonic  of  Colombo  and  wine  of 
ipecac  before  meals.  A  teaspoonful  of  Parish's  compound  syrup  of 
phosphates,  well  diluted,  was  given  after  meals. 

The  constitutional  treatment  consisted  simply  of  iron  tonics,  a 
laxative  pill,  plenty  of  nourishing  food,  and  a  very  little  exercise. 
Once  a  week  I  removed  the  secretion  from  the  cervix,  then  applied 
carbolic  acid  and  iodine,  and  ordered  a  hot-water  douche  night  and 
morning.  The  local  application  caused  pain  for  several  hours,  and 
did  not  appear  to  do  any  good.  I  passed  a  medium-sized  curette 
into  the  uterus,  and  gently  curetted  the  entire  mucous  membrane 
of  the  body  ;  this  brought  away  considerable  serum  and  blood, 
some  of  which,  from  its  dark  color,  had  evidently  been  retained  for 
a  considerable  time.  There  was  also  muco-purulent  material  which 
came  away  at  the  same  time,  but  this  may  have  come  from  the  cer- 
vix. On  carefully  examining  all  that  was  removed  from  the  uterus, 
several  little  masses  of  fungous  material  were  found,  and  several 
shreds  that  looked  like  portions  of  the  epithelial  layer  of  a  thickened 
and  softened  membrane. 

The  curetting  seemed  to  be  a  failure,  so  far  as  obtaining  any 


21Q  DISEASES  OF  WOMEN. 

large-sized  f ungosities  which  I  had  been  led  to  suspect  existed  from 
the  frequent  and  profuse  menstruation.  Considerable  pain  was 
caused  by  the  use  of  the  curette,  and  it  lasted  for  several  hours,  but 
finally  passed  away.  The  patient  also  complained  of  being  faint 
and  having  nausea,  and,  as  she  appeared  pale  after  the  operation, 
I  have  no  doubt  that  her  suffering  was  very  great,  though  she  was 
a  brave  lady,  and  did  not  complain  without  cause.  There  was  con- 
siderable oozing  of  bloody  serum  from  the  uterus  after  the  curet- 
ting. About  five  days  afterward  an  examination  revealed  a  copious 
discharge  of  cervical  secretion,  which  was  rather  dark  in  color  and 
slightly  yellow,  as  if  it  contained  pus.  Very  small  clots  of  blood 
were  also  found  entangled  in  it.  The  cervix  was  then  freed  from 
the  secretion,  and  iodine  and  carbolic  acid  again  applied.  The  next 
menstrual  flow  came  on  at  the  proper  time  and  was  quite  free,  but 
it  did  not  last  quite  as  long  as  usual.  Two  days  after  the  flow  had 
subsided  I  again  used  the  curette,  with  the  result  of  bringing  away 
some  blood  and  muco-serous  material,  but  no  shreds  of  membrane 
nor  fungosities.  The  patient  suffered  much  less  this  time  from 
the  treatment.  From  this  onward,  once  a  week,  a  pencil  made  of 
cocoa-butter,  and  as  much  iodoform  as  the  butter  would  take  up 
(about  four  grains  in  all),  was  passed  up  into  the  cavity  of  the 
uterus  as  near  to  the  fundus  as  possible ;  carbolic  acid  and  iodine 
were  applied  to  the  cervical  canal.  This  treatment  seeming  ef- 
fectual, it  was  repeated  once  a  week  for  about  two  months  ;  during 
this  time  the  uterus  diminished  in  size,  the  discharge  also  became 
less,  and  changed  to  the  character  of  that  usually  found  in  cervical 
endometritis.  The  menstruation  then  became  regular  as  to  time 
and  less  profuse,  and  did  not  last  longer  than  the  usual  time.  The 
intra-uterine  applications  were  then  suspended,  except  the  applica- 
tion of  iodine  and  carbolic  acid,  which  was  continued  once  a  week 
to  the  cervical  canal  for  about  two  months  longer.  She  had  then 
improved  so  much  in  her  general  condition,  and  the  uterus  appear- 
ing to  be  normal,  except  that  she  still  had  sliglit  cervical  leucorrhoia, 
I  unwisely  told  her  that  she  was  quite  well,  and  she  did  not  return 
for  any  after-treatment  for  six  months.  Her  leucorrhtea  at  this  time 
became  again  rather  troublesome,  and  she  came  back  for  further 
care.  I  then  found  that  her  general  condition  was  entirely  satis- 
factory ;  her  menstrual  flow  was  regular  and  normal ;  the  internal  os 
had  contracted  to  its  natural  size ;  the  uterus  measured  three  inches 
only  in  its  longest  diameter,  and  all  that  remained  of  the  former 
trouble  was  a  hypersemic  state  of  the  cervical  mucous  membrane, 
with  leucorrhoea ;  this  was  treated  for  about  six  weeks  with  one  part 


CORPOREAL  ENDOMETRITIS.  21Y 

of  carbolic  acid  to  three  of  iodine,  and  then  slie  was  dismissed  per- 
fectly well. 

I  have  been  informed  that  she  has  given  birth  to  a  child  since 
she  was  under  my  care. 

Chronic  Corporeal  Endometritis. — The  patient  was  twenty-nine 
years  old,  and  had  one  child  when  twenty-three,  and  a  miscarriage 
when  twenty -live  years  of  age.  Up  to  the  time  of  her  miscarriage 
her  health  had  been  very  good,  but  from  this  time  she  began  to 
suffer. 

The  menses,  formerly  normal,  began  to  be  too  free,  and  were 
attended  with  pain.  In  fact,  from  the  time  of  the  miscarriage  she 
had  menorrhagia  and  dysmenorrhoia,  and  both  became  more  marked 
as  time  went  on.  The  pain  in  the  uterus  at  the  time  of  the  menses 
was  not  acute,  but  was  continuous  and  aching.  It  began  a  day  or 
two  before  the  flow  and  continued  until  the  flow  ceased,  and  some- 
times for  several  days  after.  There  was  some  irregularity  about  the 
recurrence  and  quantity  of  the  menses,  and  she  observed  that  when 
the  flow  was  very  free  the  pain  was  not  so  severe.  At  some  of  the 
menstrual  periods  the  flow  would  begin  and  go  on  for  a  day  and 
then  stop  for  hours,  and  then  come  on  again  quite  freely.  When 
these  interruptions  took  place  there  usually  were  clots  passed,  which 
evidently  came  from  the  uterus,  because  they  were  expelled  after 
pains  which  differed  from  the  usual  pain  in  being  more  acute  and 
intermittent. 

The  menorrhagia  and  dysmenorrhoea  became  gradually  worse, 
the  pain  being  greater  when  the  flow  was  less.  She  became  much 
exhausted  at  each  period,  either  from  pain,  loss  of  blood,  or  both. 
Throughout  the  whole  course  of  the  affection  she  had  a  discharge 
from  the  uterus  which  was  sero-purulent. 

At  times,  especially  before  the  menstrual  period,  there  was  a  cer- 
vical leucorrhoea,  but  the  discharge  from  the  body  of  the  uterus  was 
most  marked  and  continuous.  It  was  more  yellowish  in  color,  less 
tenacious  than  cervical  leucorrhoea  usually  is,  and  oftentimes  it  was 
tinged  with  blood  and  quite  offensive  in  odor. 

There  was  much  backache,  pain  in  the  pelvis,  and  wandering 
pains  in  the  abdomen.  The  appetite  was  capricious  ;  at  times  fairly 
good,  and  at  other  times  very  poor.  She  often  had  nausea,  which 
lasted  for  a  short  time.  The  bowels  were  constipated,  and  she  was 
greatly  tormented  with  flatulence.  Her  ultimate  nutrition  was  poor ; 
she  had  lost  flesh,  and  on  her  face  there  were  many  large  blotches. 

The  nervous  system  was  very  considerably  disturbed.  Originally 
of  a  cheerful  disposition,  she  became  irritable  and  emotional.    Sleep 


218  DISEASES  OF  WOMEN. 

was  often  broken  at  night,  and  she  had  unpleasant  dreams.  During 
the  day,  especially  after  eating,  she  became  drowsy,  but  seldom  could 
sleep,  if  she  tried  to  do  so.  In  other  words,  she  was  anaemic  and 
neurasthenic. 

She  suffered  at  times  from  a  spasmodic  cough,  due  evidently  to 
deranged  innervation.  There  was  no  organic  disease  of  the  lungs  or 
bronchi.  The  general  treatment  was  tonic  and  sedative.  Mild  lax- 
atives were  also  given.  Locally,  the  hot-water  douche  was  used, 
and  equal  parts  of  iodine  and  carbolic  acid  were  applied  to  the  cervix. 
This  did  not  give  any  relief  to  the  local  symptoms,  and  her  general 
condition  improved  very  little.  The  menstrual  flow  was  as  free  and 
painful  as  before. 

The  curette  was  used,  and  some  fungous  material  removed  ;  after 
this  she  felt  better,  and  the  menstrual  flow  was  more  natural.  Sub- 
sequently she  neglected  her  treatment,  and  in  a  few  months  all  the 
old  symptoms  returned. 

She  was  anesthetized,  the  cervix  fully  dilated,  and  curetting 
employed.  A  large  quantity  of  polypoid  material  was  removed,  the 
uterus  washed  out  with  a  five-per-cent  solution  of  carbolic  acid 
and  thirty  per  cent  of  glycerin  and  then  packed  with  gauze, 
which  was  removed  at  the  end  of  three  days.  Tlie  corporeal 
endometritis  was  completely  relieved. 

The  constitutional  treatment  was  kept  up,  and  an  application 
was  made  after  each  menstruation  for  three  months,  which  arrested 
the  slight  catarrh  of  the  cervix. 


CHAPTER   XI. 

SUBINVOLUTION. 

Subinvolution  of  the  Uterus  after  Parturition.  —  The  great  in- 
crease in  the  size  of  the  uterus  during  gestation,  and  its  rapid  reduc- 
tion after  delivery,  are  among  the  most  remarkable  phenomena  in 
the  animal  economy. 

The  uterus  during  nine  months  increases  from  about  two  ounces 
to  two  pounds  in  weight  during  the  evolution  of  gestation,  and  it  is 
reduced  by  involution  in  the  short  space  of  two  or  three  weeks. 
This  process  of  involution  (by  which  the  uterus  is  reduced  to  its 
original  size)  is  a  transformation  and  absorption  of  the  tissues.  The 
structural  elements  of  the  uterus,  which  are  no  longer  needed,  un- 
dergo fatty  degeneration  and  absorption,  and  are  in  that  way  dis- 
posed of. 

The  time  required  for  this  involution  to  take  place,  and  the 
causes  which  may  interrupt  it,  have  been  clearly  pointed  out  by  Dr. 
Alexander  Sinclair,  of  Boston,  in  vol.  iv  of  the  "  Transactions  of  the 
American  Gynecological  Society,"  1879.  Dr.  Sinclair  gives  the  re- 
sults of  careful  measurements  of  the  uterus  in  one  hundred  and  eight 
cases.  These  measurements  were  made  from  twelve  to  thirty-six 
days  after  delivery,  the  average  being  sixteen  days.  In  the  great 
majority  of  these  cases  the  uterus  had  been  reduced  to  its  normal 
size  at  the  end  of  three  weeks.  In  one  the  uterus  measured  two  and 
one  haK  inches  on  the  twelfth  day.  This  shows  the  wonderful  ra- 
pidity with  which  this  involution  goes  on. 

In  all  the  cases  in  which  the  involution  was  retarded,  there  were 
present  certain  morbid  states,  such  as  laceration  of  the  perinaeum  or 
cervix  uteri,  metritis,  or  septicaemia. 

These  observations  of  Dr.  Sinclair's  are  of  the  highest  value  in 
showing  the  time  required  for  the  process  of  involution,  and  also  the 
conditions  which  interrupt,  retard,  or  arrest  it. 
Pathology. — In  uncomplicated  cases  there  are  no  inflammatory 

319 


220  DISEASES  OF  WOMEN. 

products,  nor  are  there  any  new  tissue  formations.  The  structures 
of  the  uterus  are  the  same  as  in  the  normal  state,  but  developed  by 
gestation.  In  Dr.  Snow  Beck's  case  the  microscopical  appearances 
were  like  tliose  found  in  the  middle  period  of  uterogestation.  In 
other  cases  evidences  of  fattv  degeneration  have  been  observed  in 
the  muscular  tissues. 

AVhen  the  involution  has  been  arrested  bv  puerperal  metritis,  the 
products  of  the  inflammation  are  found.  According  to  Dr.  Xoeg- 
geratli,  these  products  are  inflammatory  exudations  and  hyperplasia 
of  the  cells  of  the  areolar  tissue. 

Syinptomatology. — I  have  never  observed  any  symptoms  which 
were  specially  characteristic  of  imperfect  involution.  The  history 
of  the  delivery  and  subsequent  progress  usually  presents  some  fact 
which  would  suggest  possible  subinvohition. 

There  are  usually  present  leucorrhoea  and  backache,  and  pelvic 
tenesmus  upon  standing  or  walking,  but  all  these  symptoms  occur  in 
other  affections. 

Physical  Signs. — Digital  examination  shows  that  the  uterus  is 
enlarged  and  softer  than  normal.  Very  often  it  is  low  down  in  the 
pelvis.  The  vagina  also  is  found  to  be  enlarged  and  relaxed.  The 
rule  is  that  if  involution  is  arrested  in  the  uterus  it  is  also  arrested 
in  the  vagina  and  in  the  uterine  ligaments.  There  are  many  ex- 
ceptions to  this  rule,  however ;  as,  for  example,  a  laceration  of  the 
cervix  uteri  and  perinaeum  will  arrest  involution  of  the  cervix  and 
vagina,  while  the  body  of  the  uterus  may  return  through  involution 
to  its  normal  size. 

This  can  be  made  out  easily  by  the  touch  in  most  cases.  The 
sound,  used  through  the  speculum,  shows  the  exact  size  of  the  uterus, 
and  when  that  abnormal  size  occurs  after  confinement,  and  is  not 
otherwise  accounted  for,  it  is  a  reliable  sign  of  subinvolution.  The 
cerN-ix  and  vagina  are  usually  of  a  deep,  bluish-red  color,  and  there 
is  dilatation  of  the  cervical  canal,  and  usually  some  eversion  of  the 
lips  of  the  OS  externum. 

Prognosis. — Recovery  may  be  expected  under  proper  care  if 
treatment  is  begun  early  and  can  be  fully  carried  out,  and  there  are 
no  complications  which  can  not  be  removed.  In  case  that  the  tissues 
are  damaged  by  metritis  the  case  may  go  on  to  sclerosis,  and  become 
incurable.  AVhen  the  subinvolution  is  due  to  injuries  of  the  cervix, 
the  restoration  of  the  injured  parts  is  usually  followed  by  a  comple- 
tion of  the  involution. 

Causation. — Injuries,  such  as  laceration  of  the  cervix  and  peri- 
naeum,  and  septic  infection  causing  either  cellulitis,  lymphangitis,  or 


SUBINVOLUTION.  221 

metritis,  are  the  chief  causes.  Getting  up  too  early  after  confine- 
ment, and  engaging  in  hard  work  in  the  erect  position,  are  also  liable 
to  arrest  this  process.  All  the  cases  that  1  have  seen  were  traced  to 
some  of  the  above-named  causes. 

Treatment. — The  management  of  subinvolution  usually  falls  to 
the  obstetrician  in  case  he  is  on  the  watch  for  it.  When  not  com- 
plicated with  any  well-defined  puerperal  affection  it  is  apt  to  pass  for 
a  time  unnoticed,  because  it  does  not  give  rise  to  suffering  until  the 
patient  is  about  her  duties  again. 

When  the  patient  begins  to  go  about  after  her  confinement,  and 
there  is  pelvic  tenesmus,  backache,  and  leucorrhcea,  imperfect  invo- 
lution should  be  suspected ;  and,  if  the  physical  signs  confirm  the 
diagnosis,  the  patient  should  be  put  back  to  bed,  and  kept  there  for 
a  time.  If  the  recumbent  posture  is  not  sufficient  to  restore  the 
uterus  to  its  normal  position,  artificial  support  should  be  used,  either 
by  pessary  or  tampon.  The  hot-water  douche  should  be  employed, 
and  if  there  is  imperfect  involution  of  the  vagina  and  pelvic  floor, 
tannin  or  sulphate  of  zinc  may  be  occasionally  added  to  the  douche. 

In  the  past,  antiphlogistic  measures  were  employed  as  the  chief 
treatment.  Leeches  were  applied  to  the  cervix,  and  puncturing  and 
scarifying  were  employed  to  abstract  blood  from  the  uterus.  This 
depletion  is  doubtless  beneficial  when  there  is  well-marked  engorge- 
ment, and  the  general  state  of  the  patient  is  good — not  anaemic,  as  is 
generally  the  case  with  these  patients. 

Local  bloodletting  should  not  be  employed  unless  there  is  extreme 
congestion,  neither  should  it  be  repeated  more  than  once  or  twice. 
A  certain  degree  of  hypersemia  is  necessary  to  the  process  of  involu- 
tion, and  anaemia  will  arrest  the  process.  Depletion  is  only  admissi- 
ble in  morbid  hyperaemia.  That  it  is  useful  in  such  cases  is  beyond 
doubt.  The  value  of  depletion  is  seen  in  those  who  resume  the  func- 
tion of  menstruation  soon  after  delivery.  A  profuse  menstruation  is 
generally  followed  by  improvement. 

I  have  generally  relied  upon  less  depressing  measures.  While 
taking  care  of  the  general  health,  I  have  advised  rest,  the  hot  douche, 
and  tincture  of  iodine  applied  to  the  cervix,  cervical  canal,  and  upper 
portion  of  the  vagina.  When  these  have  failed,  I  have  used  elec- 
tricity in  the  same  way  as  in  the  treatment  of  uterine  fibroids,  but 
not  with  so  strong  a  current.  This  agent  is  one  of  the  most  valuable 
that  we  have.     Massage  of  the  uterus  will  also  be  found  useful. 

In  cases  of  long  standing  there  is  usually  some  injury  of  the  cer- 
vix uteri  or  the  pelvic  floor ;  when  such  is  the  case,  the  lacerations 
must  be  repaired  before  involution  will  be  completed. 


222  DISEASES  OP  WOMEN. 

It  1*8  almost  needless  to  add  that  all  complicating  conditions,  such 
as  endometritis,  should  have  due  attention. 

Superinvolution  of  the  Uterus  after  Parturition. — This  affection 
was  iirst  described  bj  Sir  James  Y.  Simpson,  and  illustrated  with 
cases  which  occurred  in  his  practice. 

I  presume  it  must  be  a  very  rare  condition.  I  have  not  seen  a 
case  about  the  diagnosis  of  which  I  felt  sure.  Premature  atrophy  of 
the  uterus  I  have  seen,  due  to  destructive  disease  of  the  ovaries,  re- 
moval of  the  ovaries,  and  certain  peculiar  states  in  which  the  meno- 
pause occurred  prematurely,  but  a  case  not  so  accounted  for  has  not 
occurred  in  my  practice.  I  saw  a  patient  once  in  consultation,  six 
months  after  her  confinement,  who  suffered  from  pain  in  the  abdo- 
men, which  was  due  apparently  to  adhesions  from  an  old  peritonitis. 
The  uterus  was  very  small  for  one  who  had  borne  children,  in  fact  it 
was  below  the  size  of  a  virgin  uterus.  The  menses  had  been  scanty. 
I  made  a  diagnosis  of  superinvolution,  and  gave  the  attending  phy- 
sician a  brief  clinical  lecture  on  the  subject.  He  examined  the  uterus 
afterward,  and  confirmed  my  statement  regarding  the  size  of  it. 
While  I  felt  sure  that  the  ]3ain  present,  and  for  which  I  was  con- 
sulted, was  in  no  way  connected  with  the  small  uterus,  I  took  occasion 
to  say  that  the  patient  would  remain  sterile ;  and  I  also  predicted 
an  early  menopause.  To  my  surprise  she  gave  birth  to  a  healthy 
child,  of  full  size,  about  one  year  after  I  had  made  the  diagnosis. 

Perhaps  superinvolution,  to  a  certain  extent,  may  not  necessarily 
cause  sterility,  and  my  diagnosis  may  in  this  case  have  been  correct, 
but  I  do  not  believe  so. 

Owing  to  my  lack  of  personal  knowledge  on  this  subject,  I  will 
here  give  in  full  the  case  reported  by  Sir  James  Y.  Simpson,  in  his 
work  on  "Diseases  of  Women"  : 

"  The  subject  of  this  rare  pathological  affection  began  to  men- 
struate at  the  age  of  thirteen,  and  the  catamenia  recurred  regularly 
every  four  weeks  till  she  became  pregnant  when  eighteen  years  old. 
Utero-gestation  went  on  without  any  unusual  phenomena  to  the  full 
t3rm ;  and  her  parturition  was  natural  but  tedious,  a  male  child  being 
born  after  a  labor  of  seventeen  hours.  Nothing  unusual  occurred 
during  her  puerperal  convalescence  and  lactation.  But  subsequent 
to  delivery  she  never  menstruated.  She  was,  however,  subject  to 
frequent  attacks  of  diarrhea,  which  she  herself  believed  to  be  gener- 
ally most  severe  at  recurring  monthly  intervals ;  and  the  dejections 
were  then  sometimes  tinged  with  blood. 

"  Two  years  after  accouchement  she  became  a  patient  in  the  fe- 
male ward  of  the  Royal  Intirmar}^,  complaining  of  the  state  of  amenor- 


SUBINVOLUTION.  223 

rhoea,  with  attendant  broken  health.  She  suffered  from  pain  in  the 
back  and  hypogastrium,  with  a  sensation  of  weight  and  pressure  in 
the  pelvic  region  ;  dysuria ;  a  furred  tongue ;  and  a  weak  compressi- 
ble pulse,  generally  beating  from  80  to  90  in  the  minute.  She  was 
thin,  feeble,  and  ansEmic  in  appearance.  The  mammae  were  shrunk 
and  flat.  For  some  time  before  admission  she  had  suffered  much 
from  occasional  headaches  and  giddiness ;  frequent  nausea  and  vom- 
iting ;  palpitation  and  occasional  rigors. 

"  On  making  a  vaginal  examination,  I  found  the  uterus  small  and 
mobile.  The  cervix  uteri  was  much  atrophied,  and  the  vaginal  por- 
tion of  it  scarcely  made  any  projection  into  the  canal  of  the  vagina. 
The  OS  uteri  was  so  much  contracted  as  to  admit  a  surgeon's  probe 
with  difficulty.  It  was  dilated  by  a  slender  bougie  being  left  in  for 
two  or  three  days ;  and,  when  the  uterine  sound  was  subsequently 
used,  the  uterine  cavity  was  found  to  be  only  one  and  a  half  inch 
in  length,  or  about  an  inch  less  than  normal. 

"  A  variety  of  means  was  employed  with  the  view  of  benefiting 
the  general  health  of  the  patient,  and  of  exciting  action  in  the  uterine 
system,  but  with  little  or  no  effect. 

"  Diarrhcea  repeatedly  occurred  during  the  three  or  four  weeks 
she  remained  under  my  care,  requiring  the  free  use  of  opiates  for  its 
restraint ;  and  as  the  uterine  symptoms  did  not  at  the  time  seem  to 
admit  of  special  attention  and  treatment,  the  patient  was  transferred 
to  one  of  the  general  wards  of  the  hospital,  where  she  was  placed 
under  the  care  of  my  colleague.  Dr.  Bennett. 

"  During  the  following  month  the  diarrhoea  recurred  from  time 
to  time  very  severely.  At  last  anasarca  in  the  lower  extremities  and 
albuminuria  supervened  ;  ascites  followed ;  and  shortly  afterward  her 
face  and  arms  became  oedematous.  About  a  month  after  these  symp- 
toms appeared  delirium  at  last  came  on,  the  f^ces  passed  involun- 
tarily, and  ultimately  she  died  in  a  state  of  prolonged  coma. 

"  On  post-mortem  inspection  some  crude  tubercles  were  found  in 
both  lungs,  especially  in  the  left.  The  liver  was  enlarged,  and  showed 
some  fatty  transformation.  The  kidneys  presented  also  some  stearoid 
degeneration,  and  in  the  right  there  was  in  addition  a  small  tubercu- 
lar abscess.  The  large  intestines  were  very  much  thickened  in  their 
parietes,  and  contracted  in  their  caliber,  while  their  mucous  mem- 
brane was  ulcerated  in  various  parts.  Along  the  lower  end  of  the 
ileum  several  large  ulcerations  were  seen  running  circmnferentially 
around  the  interior  of  the  bowel.  One  or  two  ulcerations  were  also 
found  in  the  stomach.  The  uterus  was  very  small,  and  atrophied  in 
its  length  and  breadth,  its  size  being  diminished  about  a  third  below 


224  DISEASES  OF  WOMEN. 

the  natural  standard  in  all  its  measurements,  and  its  parietes  were 
correspondingly  thin  and  reduced.  The  whole  length  of  the  uterine 
cavity  from  the  os  to  the  fundus  was  not  more  than  one  inch  and  a 
half,  while  the  normal  uterus  usually  measures  in  this  direction  two 
inches  and  a  half.  When  a  section  was  made  of  the  posterior  wail 
of  the  organ,  the  thickness  of  its  parietes  at  their  deepest  or  moct 
developed  point  was  not  above  three  Hues,  instead  of  the  normal 
measurement  of  five  or  six  lines.  The  tissue  of  the  uterus  appeared 
dense  and  fibrous,  and  the  section  of  it  presented  the  orifices  of  nu- 
merous small  vessels.  The  ovaries  seemed  also  much  atrophied,  and 
smaller  than  natural.  Their  tissue  was  dense  and  fibrous,  and  pre- 
sented no  appearance  of  Graafian  vesicles.  There  was  no  inflamma- 
tory deposit  on  the  peritoneal  surface  of  the  uterus  or  its  appendages ; 
but  some  thick  pus,  or  tubercular  matter,  existed  in  the  distended 
cavity  of  the  right  Fallopian  tube." 


CHAPTER   XII. 

SCLEROSIS    OF    THE   UTEEUS. 

Fifteen  years  ago  I  employed  this  term  to  designate  an  affection 
of  the  uterus,  which  up  to  that  time  had  been  known  by  a  variety  of 
names — such  as  chronic  interstitial  metritis,  hypertrophy,  chronic 
inflammatory  hypertrophy,  and  areolar  hyperplasia.  Subsequently 
Gallard  used  the  same  term  in  the  same  way. 

This  affection  of  the  uterus  is  a  change  of  structure  produced  by 
a  pre-existing  inflammation  or  derangement  of  nutrition,  and  may 
be  more  properly  considered  as  the  product  of  morbid  action,  rather 
than  active  disease.  The  term  which  I  have  selected,  therefore, 
more  clearly  indicates  the  true  nature  of  the  affection  than  the  names 
of  the  affections  or  processes  which  produce  it,  and  by  which  it  has 
heretofore  been  designated. 

Pathology. — This  comprises  certain  changes  of  structure,  mostly 
of  the  middle  coat  of  the  uterus,  which,  as  already  stated,  have  been 
caused  by  preceding  morbid  processes. 

This  change  of  structure  consists  in  an  excess  of  connective  tissue, 
the  result  of  an  areolar  hyperplasia.  This  element  in  the  structure 
of  the  uterine  walls  rapidly  increases,  encroaching  upon  the  mus- 
cular element,  and  more  especially  upon  the  blood-vessels  in  the 
connective  tissue.  The  result  is  marked  increase  in  the  density  of 
the  tissues,  and  anaemia  from  pressure  upon  the  vessels.  There  is 
frequently  an  increase  in  the  size  of  the  whole  organ,  but  in  some 
cases  the  uterus  is  not  enlarged.  In  fact,  the  uterus  may  notably 
diminish  in  size,  when  the  hyperplasia  is  suflficient  to  cause  atrophy 
of  the  other  tissues  of  the  uterus. 

The  histological  composition  of  the  tissues  differs  in  different 
cases,  and  in  different  stages  of  the  development  of  the  affection. 

In  those  cases  which  have  their  genesis  in  puerperal  metritis 
there  is  generally  at  first,  in  addition  to  hyperplasia  of  connective 
tissue,  a  fatty  degeneration  of  the  muscular  tissue,  which  has  not 

IG  225 


226  DISEASES  OF  WOMEN. 

been  disposed  of  by  the  process  of  involution.  There  are,  also,  in 
some  cases,  some  of  the  products  of  the  inflammation  in  the  form  of 
exudation  into  the  tissues.  All  these  give  the  uterus  its  increase  in 
size,  which  to  some  extent  is  permanent,  although  the  organ  may 
diminish  very  much  in  time. 

The  hyperj^lasia  of  the  connective  tissue  causes  atrophy  of  the 
other  tissues,  and  to  that  extent  the  uterus  is  reduced  in  size.  When 
tlie  sclerosis  follows  non-puerperal  metritis  the  uterus,  which  dur- 
ing the  stage  of  inflammatory  engorgement  was  larger  than  normal, 
may  become  reduced  to,  or  even  below,  its  normal  size.  This  is 
more  likely  to  occur  when  the  hyperplasia  is  extensive,  and  involves 
all  the  tissues  of  the  uterus  and  their  blood-vessels. 

Sclerosis  may  be  general  or  local.  When  due  to  puerperal  or 
chronic  metritis,  or  to  deranged  nutrition  from  long-continued  con- 
gestion, the  whole  organ  shares  in  the  morbid  process.  Wlien  it  is 
due  to  some  injury  and  inflammation,  or  deranged  nutrition  of  the 
cervix,  the  body  may  remain  normal.  Circumscribed  patches  of 
sclerosis  in  the  body  or  cervix  have  not  been  found. 

Finally,  this  is  a  permanent  affection.  When  once  the  changes 
of  structure  have  taken  place  they  remain,  to  a  certain  extent  at 
least.  There  is  no  tendency  to  complete  restoration  of  the  normal 
tissue.  There  may  be  a  slight  diminution  of  the  size  of  the  uterus. 
I  am  inclined  to  think  that  even  at  the  menopause,  the  period  at 
which  almost  all  uterine  affections  subside,  this  lingers,  and  possibly 
remains  always. 

I  have  had  an  opportunity  of  observing  several  cases  some  time 
after  the  change  of  life,  and  the  uteras  in  all  of  them  was  lai'ger  than 
it  should  be.  Dr.  Noeggerath  claimed  that  sclerosis,  or  chi'onic  me- 
tritis, as  he  called  it,  predisposed  to  cancer  of  the  uterus.  This  may 
be  so.  There  is  in  this  affection  a  change  of  structure,  and,  accord- 
ing to  the  rule  in  pathology,  a  consequent  lowering  of  the  vitality 
of  the  part,  and  a  predisposition  to  further  degeneration, 

Sjinptomatology . — The  clinical  history  of  this  affection  differs  in 
many  points  from  that  of  other  forins  of  uterine  disease,  but  there 
are  no  symptoms  that  are  diagnostic. 

There  is  more  marked  constitutional  disturlmnce  in  the  pro- 
nounced eases  than  is  found  in  the  average  inflanmiatory  affections. 
This  may  be  due  largely  to  the  exhausting  effect  of  the  disease  which 
preceded  the  sclerosis — this  being  quite  sufiicient  to  keep  up  the 
general  ill-health. 

There  is  derangement  of  menstruation,  usually  anienorrhcea.  In 
well-marked  cases  neuralgic  pains  in  the  uteras  are  frequently  pres- 


SCLEROSIS  OF  THE  UTERUS.  227 

ent,  which  are  much  worse  at  the  menstrual  period.  The  pain  at 
this  time  often  begins  before  the  How  and  continues  throughout  the 
whole  period,  and  sometimes  a  day  or  so  after.  In  some  cases  the 
pain  is  acute  and  irregular,  in  others  of  a  dull,  aching  character,  and 
in  a  few  both  varieties  of  pain  coexist.  The  form  of  suffering  may 
be  likened  to  a  very  great  aggravation  of  all  the  disagreeable  feelings 
of  an  ordinary  menstruation. 

The  clinical  history  (so  far  as  symptoms  are  concerned)  in  the 
inter-menstrual  period  closely  resembles  that  of  corporeal  endome- 
tritis. 

Physical  Signs. — These  are  briefly  as  follows :  Ansemia  of  the 
uterus,  indicated  by  the  pale  appearance  of  the  cervix,  as  seen  through 
the  speculum,  and  suggested  by  amenorrhoea ;  enlargement  and  in- 
duration of  the  uterine  walls,  as  detected  by  touch  and  sound ;  in- 
creased length  of  the  cavity  of  the  uterus  without  increase  of  the 
lateral  and  antero-posterior  diameters ;  slight  retraction  of  the  lips 
of  the  OS  externum,  and  the  small  size  of  the  cervical  canal  compared 
with  the  size  of  the  walls  of  the  cervix. 

The  hardness  of  the  uterus  is  a  most  valuable  sign,  but  one  that 
is  not  easily  detected.  To  the  touch,  the  uterus  does  not  in  all  cases 
appear  to  be  more  dense  than  the  virgin  uterus,  but  where  it  is  en- 
larged it  is  softer  in  consistency,  except  in  sclerosis ;  hence,  when 
there  is  an  increase  in  size  and  induration,  not  due  to  fibroma,  the 
evidence  is  in  favor  of  sclerosis. 

In  the  great  majority  of  cases  the  uterus  is  more  tender  than  in 
any  other  affection,  except  acute  metritis,  and  endometritis  with  flex- 
ion. The  touch  excites  this  sensitiveness,  and  the  passage  of  the 
sound  causes  marked  pain. 

Prognosis. — Sclerosis  being  a  permanent  change  of  structure, 
recovery  with  or  without  treatment  is  the  exception.  By  reheving 
any  complication  which  may  be  present,  such  as  displacement,  the 
patient  may  be  made  sufficiently  comfortable  to  reach  the  menopause, 
and  then  recovery  may  take  place. 

Sclerosis  of  the  cervix  may  be  relieved  to  a  great  extent,  some- 
times completely,  by  trachelorrhaphy,  if  the  cervix  has  been  lacer- 
ated. 

In  case  the  cervix  has  not  been  injured  its  size  can  be  reduced, 
and  the  tissues  may  become  softened  and  the  nutrition  improved  by 
taking  out  a  V-shaped  piece  on  each  side,  and  bringing  the  parts  to- 
gether, as  in  the  operation  for  laceration. 

Causation. — The  causes  of  this  affection,  given  in  the  literature 
of  medicine,  are  che  same  as  those  of  almost  all  other  inflammatory 


228  DISEASES  OF   WOMEN. 

diseases  of  the  uterus.  In  the  cases  which  have  come  under  my  own 
observation,  they  were  either  acute  metritis  following  child-bearing, 
or  miscarriage  or  long-continued  general  endometritis,  and  injuries 
to  the  cervix  during  labor. 

This  leads  me  to  believe  that  these  are  the  only  causes  of  this 
affection.  In  fact,  as  sclerosis  is  the  result  of  a  deranged  nutrition 
of  an  inflammatory  nature,  it  follows  that  the  cause  must  be  a  pre- 
ceding metritis,  partial  or  general. 

Treatment. — Sclerosis  is,  of  course,  a  preventable  disease  in  the 
majority  of  cases.  If  the  inflannuatory  affections  which  lead  to  it 
are  carefully  managed  the  structural  changes  will  be  avoided,  except- 
ing in  severe  puerperal  metritis. 

When  once  the  changes  in  the  tissues  which  constitute  true  scle- 
rosis have  occurred,  it  is  still  a  question  whether  any  known  treat- 
ment can  entirely  relieve  it.  As  already  stated  in  the  prognosis, 
benefit  may  be  obtained  by  removing  complications,  such  as  lacera- 
tion of  the  cervix.  In  xhe  hope  of  causing  absorption  of  the  areolar 
tissue,  mercury,  iodine,  copper,  and  belladonna  have  all  been  em- 
ployed ;  and,  it  is  needless  to  say,  that  the  hot- water  douche  has  also 
been  frequently  tried. 

Dr.  Noeggerath,  of  New  York,  recommends  amputation  of  the 
cervix,  permitting  the  stump  to  heal  by  granulation  instead  of  cover- 
ing it  over  with  vaginal  mucous  membrane.  This  he  deems  advisa- 
ble, not  only  in  the  hope  of  relieving  the  sclerosis  and  to  counteract 
the  effect  of  the  operation,  but  also  to  prevent  the  development  of 
malignant  disease. 

So  far  as  my  own  personal  observation  goes,  I  am  obliged  to  say 
that  I  have  not  seen  much  benefit  from  any  such  treatment,  and  have 
come  to  look  upon  ths  disease  as  an  incurable  one. 

There  is  one  remedy  which  promises  to  be  useful,  and  that  is 
electricity  ;  but  I  have  not  had  experience  enough  in  its  use  to  enable 
me  to  speak  definitely  regarding  it.  I  may  say,  however,  that  it 
promises  more  than  anything  else  that  I  am  familiar  M'ith,  but  more 
extensive  observation  is  necessary  to  determine  its  true  value. 

ILLUSTRATIVE    CASES. 

Sclerosis  of  the  Cervix  Uteri. — This  case,  M^hose  history  I  give,  is 
one  of  the  very  few  that  I  have  seen  of  sclerosis  of  the  cervix,  not 
accompanied  with  laceration.  It  is  possible  that  the  cervix  had 
been  lacerated  during  one  of  the  patient's  confinements,  and  that 
the  M'ound  had  healed,  but  I  could  not  find  any  trace  of  such  injury. 

The  patient  was  thirty-one  years  old,  and  had  borne  four  chil- 


SCLEROSIS  OF  THE  UTERUS.  229 

dren  ;  tlie  last  one  three  years  before  the  time  when  this  history  was 
taken.  Slie  did  not  recover  from  this  confinement  as  well  as  she 
had  in  previous  ones,  but  I  could  not  get  any  history  of  serious 
puerperal  disease  at  that  time. 

After  the  confinement  her  health  was  poor,  and  she  gave  the 
history  of  some  uterine  disease.  Her  menstruation  was  normal,  but 
attended  with  more  pelvic  pain  than  formerly.  She  had  suffered 
from  leucorrhoea,  but  this  had  gradually  diminished.  At  my  first  ex- 
amination I  found  the  body  of  the  uterus  normal,  but  the  cervix  was 
much  enlarged  and  hard  to  the  touch  ;  the  os  was  circular  and  small 
in  proportion  to  the  size  of  the  cervix — it  was  an  inch  and  three 
quarters  in  diameter.  To  the  touch  the  cervix  appeared  to  be 
as  large  as  the  body  of  the  uterus.  There  was  no  other  lesion 
found  except  that  there  was  prolapsus  in  a  slight  degree.  She 
was  treated  with  the  hot  douche  and  applications  of  tincture  of 
iodine,  but  without  effect.  I  then  removed,  with  the  hawkbill 
scissors,  a  large  V-shaped  piece  from  the  lateral  walls  of  the  cervix, 
and  closed  the  wound  with  sutures,  making  an  operation  like  that 
for  bilateral  laceration.  Healing  was  prompt  and  complete,  and 
the  size  of  the  cervix — at  least  the  vaginal  portion  of  it — was  much 
reduced. 

She  was  better  for  the  operation,  and  at  the  end  of  one  year  I 
found  that  the  whole  cervix  was  nearly  of  its  normal  size,  and  that 
the  tissues  were  soft  and  more  vascular.  The  operation  had  the 
effect  of  changing  the  nutrition  of  the  parts,  and  causing  absorption 
of  the  new  tissue. 

In  sclerosed  tissue  due  to  laceration  of  the  cervix,  I  have  fre- 
quently seen  such  favorable  changes  after  operations. 

Sclerosis  Uteri,  following  Puerperal  Metritis. — This  patient  was 
thirty-five  years  old,  had  been  pregnant  five  times,  and  given  birth 
to  four  living  children.  While  pregnant  at  the  seventh  month  with 
her  fourth  child  she  received  an  injury  which  caused  her  to  give 
birth  to  a  dead  foetus  a  few  days  afterward. 

During  her  fifth  pregnancy  she  received  a  shock  from  seeing  a 
friend  in  a  convulsion  ;  labor  came  on  immediately,  and  she  was  de- 
livered of  a  seven  months'  child.  Soon  after  her  confinement  she 
complained  of  pain  and  tenderness  in  the  region  of  the  uterus,  fol- 
lowed by  fever.  These  symptoms  extended  over  a  period  of  three 
weeks,  and  there  can  be  little  doubt,  from  the  history  given,  that 
she  had  acute  puerperal  metritis,  which  left  her  health  permanently 
impaired.  Since  that  time  her  menses  have  been  irregular,  scanty, 
and  attended  with  pain.     At  times  she  has  a  menstrual  molimen, 


230  DISEASES  OF  WOMEN. 

but  no  catamenial  flow.  During  the  last  year  she  has  menstruated 
twice,  the  last  time  three  months  ago.  This  is  the  previous  history 
of  the  case. 

She  now  suffers  from  extreme  debility  and  anaemia,  which  is 
shown  by  her  general  appearance ;  she  also  complains  of  ill-deiined 
aching  pains  throughout  the  pelvis,  and  in  the  sacral  region  ;  occa- 
sionally she  has  very  slight  leiicorrhoea.  Her  digestive  organs  are 
also  very  much  deranged,  and  her  nervous  system,  from  the  joint 
action  of  disease  and  drugs,  is  a  miserable  wreck. 

By  physical  exploration  I  find  that  the  uterus  is  enlarged,  being 
three  quarters  of  an  inch  longer  than  normal.  The  body  and  cervix 
are  tender  to  the  touch,  and  the  sound  carried  into  the  cavity  gives 
extreme  pain.  The  cervix  is  indurated  and  smooth,  and  the  os  is 
smaller  and  more  circular  than  is  usually  found  in  those  who  have 
borne  children. 

Exploring  the  cavity  with  the  sound,  I  find  that  while  the  longer 
diameter  is  considerably  increased  the  antero-posterior  and  lateral 
diameters  are  shortened.  The  uterine  walls  appear  to  lie  in  close 
contiguity,  so  that  it  is  impossible  to  turn  the  sound  far  in  any  di- 
rection. These  signs  obtained  by  the  probe  are  of  vast  importance, 
for  they  indicate  clearly  that  the  enlargement  of  the  uterus  is  due 
to  an  actual  increase  in  the  walls  of  the  organ,  and  not  a  mere  ex- 
pansion of  its  cavity.  In  other  words,  the  growth  is  concentric,  not 
eccentric. 

The  cervix,  as  seen  through  the  speculum,  is  notably  pale ;  the 
OS  is  small,  with  its  lips  curved  inward.  This  retraction,  or  di*awing 
inward  of  the  os,  is  confirmatory  of  the  opinion  that  the  walls  of  the 
cervix  are  enlarged  more  than  the  mucous  membrane  of  the  cavity. 
When  the  mucous  membrane  of  the  cervix  is  swollen,  and  the  walls 
remain  normal,  the  lips  are  enlai'ged  or  pouting. 

Briefly,  then,  the  j^hysical  signs  indicate  that  there  exists  a  con- 
dition of  unusual  hardness  and  enlargement  of  the  uterine  walls, 
while  the  relative  size  of  the  cavity  is  lessened.  The  uterus  is  also 
anaemic,  as  can  be  seen  from  a  glance  at  the  cervix. 

It  should  be  noted  that  this  patient  has  amenorrhoea — a  condition 
that  is  much  more  common  in  the  young  than  in  those  who  have 
borne  children,  and  is  seldom  found  in  connection  with  enlargement 
of  the  uterus. 

This  form  of  sclerosis  presents  many  points  of  resemblance  to 
that  of  general  endometritis,  but  they  are  essentially  different. 

Contrasting  sclerosis  with  endometritis  gives  results  as  follows : 
The  one  begins  with  acute  inflammation  of  the  uterus,  the  other 


SCLEROSIS  OF  THE  UTERUS.  231 

does  not ;  in  tlie  one  tliere  is  amenorrhoea,  in  the  other  menorrhagia ; 
in  the  one  the  nterine  walls  are  enlai-ged  and  the  cavity  diminished, 
while  the  reverse  of  this  obtains  in  the  other ;  the  utenis  in  the  one 
is  indurated  and  anaemic,  in  the  other  it  is  relaxed  and  highly  con- 
gested. These  are  plain  outline  distinctions,  easily  recognized,  and 
characteristic  of  almost  opposite  pathological  conditions. 

Treatment  and  Prognosis  of  the  Case. — After  each  menstruation 
an  effort  was  made,  either  with  leeches  or  puncture,  to  supplement 
the  flow  by  depletion.  This  was  not  successful.  It  was  ditticult  to 
extract  blood  from  the  aniiemic  tissues,  and  what  was  accomplished 
did  not  even  relieve  the  patient.  Blistering  the  cervix  was  tried 
with  some  apparent  benefit ;  cantharidal  collodion  was  applied,  and 
a  tampon  used  to  protect  the  vagina  until  vesication  should  take 
])lace.  This  was  repeated  several  times  at  intervals  of  two  weeks, 
and  the  patient  had  less  pain  in  the  uterus  and  gained  a  little,  but 
whether  from  the  blistering  or  tonics  and  general  supporting  treat- 
ment, could  not  be  stated  with  certainty.  Iodine  was  next  tried  ;  it 
was  applied  to  the  canal  and  vaginal  surface  of  the  cervix  thoroughly 
twice  a  week,  but  she  did  not  seem  to  improve  much. 

About  this  time  some  one  in  England  reported  good  results  in 
obstinate  uterine  affections  from  vaginal  suppositories  containing 
mercury.  I  tried  these  until  slight  salivation  was  produced.  Some 
harm,  but  no  benetit  was  the  result.  Finally,  I  may  state  that  some 
relief  was  obtained,  but  not  much.  She  profited  from  constitutional 
treatment,  but  not  much  if  any  from  local  medication.  Considera- 
ble relief  was  obtained  by  wearing  a  Peaslee's  ring-pessary,  which 
gave  a  little  support  to  the  uterus,  but  it  caused  irritation,  and  had 
to  be  removed. 

"When  she  was  greatly  fatigued,  and  suffered  more  pain  than 
usual,  a  cotton  tampon  gave  relief  also. 

I  lost  sight  of  the  patient  for  a  number  of  years,  but  recently  she 
returned  to  the  city  and  called  to  see  me  about  some  trouble  of  her 
digestion.  She  told  me  then  that  she  never  fully  recovered  until  the 
menopause,  which  occiu-red  at  forty-six.  Since  that  time  she  had 
been  fairly  well. 

The  uterus,  though  larger  than  it  should  have  been  at  her  age, 
was  smaller  than  when  under  observation,  fourteen  years  before. 

Sclerosis  Uteri,  resulting  from  Endometritis  and  General  Congestion. 
— The  patient  was  twenty-four  years  old  when  flrst  seen.  She  was 
highly  refined,  and  of  a  well-marked  nervous  temperament.  She 
beffan  to  menstruate  at  the  as'e  of  fourteen,  and  had  contimied  so  to 
do  regularly,  but  had  always  had  slight  pain  at  the  menstrual  peiiods, 


232  DISEASES  OF  WOMEN. 

and  was  unusually  nervous  and  irritable  at  such  times.  She  was 
married  at  twenty-two,  and  soon  after  began  to  have  backache,  leu- 
corrhoea,  and  more  pain  than  formerly  during  menstruation,  and  the 
flow  was  more  free. 

These  symptoms  gradually  increased,  and  her  general  health  failed 
considerably.  Pain  in  the  uterus  and  general  pelvic  tenesmus  were 
added  to  her  other  symptoms,  and  after  suffering  for  two  years  in 
this  way  she  came  under  my  care. 

I  then  found  the  uterus  larger  than  it  should  have  been,  and  its 
tissues  softer  than  normal,  especially  those  of  the  cervix.  The  canal 
of  the  cervix  was  larger  than  normal,  and  the  whole  uterus  was 
tender  to  the  touch.  Passing  the  sound  caused  severe  pain.  There 
was  considerable  erosion  of  the  cervix,  the  os  externum  was  di- 
lated, and  the  mucous  membrane  was  highly  congested.  There 
was  a  free  muco-purulent  discharge  which  irritated  the  vagina  and 
vulva. 

The  usual  local  treatment  for  endometritis  was  employed,  and 
the  ordinary  means  were  used  to  improve  her  general  health.  Appli- 
cations of  nitrate  of  silver  (which  I  used  at  that  time,  according  to 
the  advice  of  my  former  teachers)  caused  great  pain,  and  were  given 
up  for  milder  means,  such  as  tincture  of  iodine,  and  tannin  and  glyc- 
erin. She  improved  very  slowly,  and  about  ten  months  after  she 
came  under  my  care  she  went  to  Europe  with  her  husband,  who  was 
called  there  on  business.  She  remained  in  England  for  about  five 
years,  and  occasionally  was  treated  by  a  distinguished  physician 
there. 

Excepting  various  kinds  of  vaginal  injections  she  had  no  local 
treatment  while  in  England.  Her  general  health  improved  very 
much,  and  she  bore  her  local  troubles  without  complaint. 

Upon  her  return  to  this  country,  I  found  that  her  menstrual  flow 
had  diminished  until  she  had  less  than  before  her  marriage.  There 
was  very  little  leucorrhoea,  and  less  pelvic  tenesmus.  There  was 
quite  as  severe  dysmenorrhoea,  and  she  had  intermittent  pain  in  the 
uterus  of  a  neuralgic  character.  The  uterus,  taken  as  a  whole,  was 
a  little  smaller,  and  indurated  to  the  touch  ;  the  canal  of  the  cervix 
and  the  cavity  of  the  body  were  decidedly  diminished  in  caliber,  and 
still  tender  to  the  touch  of  the  uterine  sound.  The  os  externum  was 
contracted,  and  its  lips  in  place  of  being  everted  as  formerly  were 
now  slightly  curved  inward.  In  place  of  the  soft  vascular  conditirm 
of  the  cervix,  present  when  she  was  first  examined,  it  was  now 
round,  well  defined,  and  rather  anaemic  in  appearance. 

It  was  only  by  referring  to  my  notes  of  the  case,  taken  at  the 


SCLEROSIS  OF  THE  UTERUS.  23S 

first  examination,  that  I  could  fully  realize  the  change  which  had 
taken  place. 

I  treated  her  for  a  short  time  in  the  hope  of  relieving  her  dys- 
menorrhoea  and  uterine  pains,  but  without  much  benefit ;  and,  as  she 
was  able  to  get  along  by  resting  at  her  menstrual  period,  she  was  dis- 
missed with  the  advice  to  await  the  menopause,  when  in  all  proba- 
bility she  would  be  relieved 


CHAPTER   XIII. 

MEHIBR ANGUS   DYSMENOEKHCEA. 

I  SHOULD  i^refer  to  call  this  affection  membranous  menorrhoea, 
believing  that  the  term  would  be  more  appropriate,  but  as  the  original 
name  has  been  longer  in  use,  and  is  familiar  to  the  profession,  I  shall 
not  attempt  to  change  it. 

This  is  an  affection  which,  although  rather  rare,  commands  very 
urgently  the  attention  of  the  gynecologist,  because  of  the  dreadful 
suffering  which  it  gives  rise  to,  and  the  obstinacy  with  which  it  has 
heretofore  resisted  treatment.  There  is  a  marked  uniformity  about 
this  disease.  In  its  j)athology  and  clinical  history  it  varies  but  little 
in  different  cases.  A  number  of  affections  resemble  it  to  a  limited 
extent,  but  it  stands  out  well  defined,  and  is  easily  detected  by  the 
experienced  diagnostician. 

Pathology. — An  exfoliation  in  mass  of  the  mucous  membrane  of 
the  cavity  of  the  body  of  the  uterus  at  the  menstrual  period  is  the 
chief  lesion  in  this  affection.  Microscopically,  the  mass  presents  all 
the  histological  elements  of  the  true  mucous  membrane  of  the  uterus, 
including  the  utricular  glands,  unchanged  by  any  new  or  abnormal 
elements.  When  it  is  expelled  entire,  it  represents  a  complete  cast 
of  the  cavity  of  the  uterus,  and  is  triangular,  with  an  irregular  open- 
ing at  each  of  the  angles,  the  one  representing  the  internal  os  uteri, 
and  the  others  corresponding  to  the  ostia  of  the  Fallopian  tubes. 
This  membrane  is  rather  ragged  on  the  outer  surface,  but  smooth  on 
the  inner,  and  looks  exactly  as  the  lining  membrane  of  the  uterus 
does  when  in  position.  The  size  is  usually  about  an  inch  long  and 
less  than  that  in  width,  and  is  generally  somewhat  larger  than  the 
normal  proportions  of  the  cavity  of  the  uterus  ;  but  this  is  not  always 
the  case.  In  this  respect  it  is  like  the  decidua  of  pregnancy ;  in 
fact,  in  general  appearance  it  closely  resembles  the  decidua  vera,  but 
there  is  a  decided  difference  in  its  microscopic  elements,  sufficient  at 
least  to  distinguish,     This  similarity  of  the  two  membranes  has  le^ 

234 


MEMBRANOUS  DYSMENORRHCEA.  235 

to  their  being  called  the  decidua  gravida  and  the  decidua  menstru- 
al is,  the  former  being  the  mucous  membrane  as  seen  in  abortion  at  a 
very  early  stage  of  gestation,  the  other  the  membrane  as  thrown  off 
at  menstruation  in  this  morbid  form, ' 

Comparing  the  changes  \7hich  the  mucous  membrane  undergoes 
in  membranous  dysmenorrhoea  with  its  changes  in  normal  menstru- 
ation, the  difference  is  as  follows :  In  normal  menstmation,  if  we 
accept  the  views  of  Dr.  Williams,  of  London,  the  whole  mucous 
membrane  undergoes  fatty  degeneration,  disintegration,  and  elimina- 
tion ;  whereas  in  membranous  dysmenorrhoea  the  mucous  membrane 
becomes  separated  from  the  walls  of  the  uterus  without  being 
changed  or  disintegrated  ;  exfoliation  and  expulsion  simply  occur. 
The  way  in  which  the  separation  of  the  mucous  membrane  takes 
place  is  not  positively  known.  It  is  presumed,  however,  that  fatty 
degeneration  in  the  deeper  structures  of  the  membrane  takes  place, 
and  thereby  it  becomes  detached  from  the  uterus.  It  is  possible, 
also,  that  the  capillary  haemorrhage,  instead  of  occurring  on  the  free 
surface  of  the  membrane,  takes  place  in  the  deeper  structures,  and 
in  that  way  dissects  off  the  membrane.  This,  however,  is  hypo- 
thetical, and  needs  confirmation.  Sometimes  the  membrane  is  ex- 
pelled in  shreds,  which  suggests  that  the  exfoliation  either  occurs 
in  spots  or  sections,  or  else  that  the  membrane  is  completely  sep- 
arated from  the  uterus,  but  becomes  broken  up  either  during  ex- 
pulsion or  in  handling  it  afterward.  It  is  much  more  probable  that 
it  is  completely  exfoliated  and  broken  up  subsequently  than  that  it 
is  separated  in  circumscribed  patches.  All  these  facts  lead  to  the 
conclusion  that  the  affection  is  a  perversion  of  nutrition  and  func- 
tion rather  than  an  organic  disease,  inflammatory  or  otherwise,  which 
gives  rise  to  this  peculiar  condition  of  the  mucous  membrane  at 
menstruation.  It  is  clearly  evident  that  there  is  nothing  pathologi- 
cal in  the  condition  of  the  mucous  membrane  itself,  but  that  the 
whole  morbid  process  consists  in  the  separation  of  the  membrane  in 
mass,  in  place  of  disintegration,  which  is  the  normal  character  of 
the  mucous  membrane  in  menstruation.  There  are  other  views 
regarding  the  pathology  of  this  affection :  one,  that  it  is  the  result 
of  gestation,  which  is  arrested  at  a  very  early  stage,  and  that  the 
membrane  thrown  off  is  really  a  decidua  vera.  That  this  theory  is 
fallacious  will  be  seen  when  the  physical  signs  of  this  affection  are 
discussed. 

The  idea  that  it  is  an  inflammatory  affection  is  not  well  sustained. 
No  such  product  or  result  of  inflammation  is  found  elsewhere  in  the 
mucous  membranes  of  the  body,  nor  is  it  necessary  that  inflammation 


236  DISEASES   OP  WOMEX. 

of  any  part  of  the  uterus  should  be  present  in  order  to  produce 
membranous  dysmenorrhea. 

Associated  with  this  membranous  dysmenorrhcea  we  occasionally 
find  inliammatory  conditions,  but  not  of  tlie  mucous  membrane  of 
the  cavity  of  the  body.  There  may  be,  and  often  is,  a  general  hy- 
pertemia  of  the  uterus  and  vagina,  but  usually  it  is  not  greater  than 
that  which  is  seen  in  normal  menstruation. 

There  is  occasionally,  in  cases  of  long  standing,  cervical  endome- 
tritis, but  this  does  not  extend  to  the  body  of  the  uterus.  In  fact,  I 
believe  that  a  well  defined  endometritis  can  not  occur  at  the  same 
time  as  membranous  dysmenorrho?a.  This  affection,  then,  is  cer- 
tainly srii  getieris,  and  is  not  the  result  of  inflammation  in  any  form 
or  in  any  stage  of  the  inliammatory  process  ;  neither  is  it  a  utero-ges- 
tation  ending  in  abortion  at  a  very  early  stage  of  pregnancy,  as  some 
have  maintained ;  neither  does  the  membrane  partake  of  the  nature 
of  any  of  the  morbid  neoplasms  which  occur  in  mucous  membranes 
elsewhere  in  the  body. 

The  mucous  membrane  in  this  affection  is  developed  in  the  nat- 
ural manner  after  each  menstruation,  and  the  gross  appearances  and 
histological  comj)osition  of  this  structure  sliow  that  it  is  normal,  and 
differs  in  no  way  from  the  mucous  membrane  of  the  uterus  up  to 
the  time  when  the  menstrual  flow  is  about  to  begin.  Perhaps  there 
is,  in  some  cases,  an  increase  in  the  quantity  of  the  membrane,  but 
only  to  a  very  limited  extent,  if  at  all.  In  short,  the  only  pathol- 
ogy connected  with  this  affection  is  in  the  manner  in  which  the 
meml)rane  is  thrown  off. 

Symptomatology. — This  affection  occurs  in  single  and  married 
women — about  as  often  in  one  class  as  the  other,  perhaps.  It  also 
occurs  in  those  who  have  borne  children,  but  in  most  of  the  cases 
that  I  have  seen  in  married  women  the  patients  have  been  sterile. 
The  recurrence  of  the  menstruation  is  generally  regular ;  sometimes 
it  is  delayed,  and  sometimes  there  is  a  sense  of  pelvic  discomfort 
before  the  menstrual  flow,  but  not  always.  The  chief  symptom  is 
the  pain  which  comes  on  usually  during  the  first  day,  sometimes 
later,  and  increases  in  severity,  and  is  somewhat  intermittent  in 
character  until  the  meiiil)rane  is  expelled,  when  it  i-ather  al)rui)tly 
subsides. 

The  flow  sometimes  is  scanty  jirevious  to  the  expulsion  of  the 
membrane,  and  after  that  it  is  generally  quite  free;  at  times  abnor- 
mally so,  and  occasionally  small  clots  are  passed. 

Sometimes  there  is  a  leucorrhteal  discharge  succeeding  the  men- 
strual flow,  the  discharge  being  occasionally  tinged  with  blof)d.     In 


MEMBRANOUS  DYSMENORRHCEA. 


237 


other  cases  the  menstrual  flow  subsides  after  the  expulsion  of  the 
membrane,  and  no  leucorrlnjea  of  any  account  occurs  afterward. 

There  is  really  nothing  in  the  clinical  history  of  this  aifection  by 
which  it  can  be  positively  distinguished  from  dysmenorrhrea  due  to 


Figs.  103,  104. — The  two  sides  of  a  half-membrane  from  a  multipara;  from  the 
cavity  of  the  body.     The  slight  puckering  present  is  due  to  alcohol. 

other  causes.     Hence  the  diagnosis  must  always  depend  upon  the 
physical  signs. 

Physical  Signs. — In  order  to  make  a  diagnosis,  it  is  absolutely 

necessary  that  the  membrane  expelled 
should  be  preserved  and  examined. 
The  gross  appearances  of  the  speci- 
men are  usually  all  that  is  necessary 
to  satisfy  the  diagnostician  regard- 
ing the  nature  of  the  affection,  but 
in  cases  where  there  is  a  doubt  the 
microscope  must  be  called  in  to  aid 
in  the  diagnosis. 

The  morbid  materials  expelled 
from  the  uterus  which  simulate  the 
membrane  produced  in  this  affection 
are  the  decidua  expelled  in  abortion 
in  the  earliest  stages  of  pregnancy ; 
the  masses  of  fibrin  which  have 
formed  in  the  uterus  in  menorrhagia ;  very  dense  masses  of  secre- 
tion from  the  cervix ;  and  the  membranous-looking  shreds  expelled 
from  the  cervix  and  vagina  after  astringent  or  caustic  applications. 


Fig.  105. — Half  a  membrane  from  a 
virgin ;  from  the  body  of  the 
uterus  only. 


238 


DISEASES   OF   WOMEN. 


^■^ 

H 

'-^H 

Hit ' 

'  '''"^H 

^^HL*'- 

1  I'l^H 

■P^'  ''^^ 

''i^^^H 

^^^^^^^E^MF  l.,j 

1 

■| 

1 

^^^^^^^^B^^ 

1 

Fig.  107.  —  Frag- 
ments of  mem- 
brane in  the  con- 
dition in  which 
they  are  often 
expelled. 


The  decidua  in  early  abortion  is  most  ditiicult  to  distinguish 
from  the  menstrual  membrane.  In  the  early  abortion  the  mem- 
brane expelled  is  usually 
larger  and  more  ovoid  or 
round,  and  not  so  mark- 
edly triangular  as  the 
decidua  of  menstruation, 
and  is  also  thicker,  and 
usually  is  accompanied 
with  villi  of  the  cho- 
rion. If  there  is  still 
a  doubt,  the  microscope 
reveals  the  fact  that  the 
menstrual  membrane  pos- 
sesses only  small  cells, 
while  those  of  the  de- 
cidua-vera  membrane  are  so  great  as  to 
be  easily  distinguished.  There  is  a  de- 
cided microscopic  difference  in  the  epi- 
thelium, the  tubes,  and  the  inter-glandular 
tissue.  This  difference  between  the  two 
membranes  is  not  only  in  the  decidua  of 
early  abortion,  but  also  in  the  decidua  of 
extra-uterine  pregnancy.  In  being  thus  able  to  distinguish  be- 
tween the  decidua  of  pregnancy  and  the  membrane  of  menstrua- 
tion, the  only  great  difficulty  in 
the  diagnosis  is  overcome. 

Inspection  will  enable  one  to  dis- 
tinguish shreds  of  fibrin,  masses  of 
unusually  dense  secretion  of  the  cer- 
vix, and  shreds  from  the  cervix 
and  the  vagina  after  astringent  ap- 
plications from  the  menstrual  mem- 
brane. 

The  diagnosis  can  l)e  made  with 
great  certainty. 

Causation. — Discarding  the  cur- 
rent views  regarding  membranous 
dysmenorrhfea — that  is,  that  it  is 
due  to  inflammation,  or  else  the  re- 
sult of  gestation — one  is  left  with 
out  any  very  rational  view  to  offer 


Fig.  106. — A  cast  from  a 
virgin,  where  the  cervix 
is  also  involved. 


Fig.  108. — A  cast  which  might  be 
mistaken  for  a  product  of  concep- 
tion :  w,  shaggy  interior ;  «,  film 
of  niiMnbrane  covering  it;  c,  fila- 
ments from  cervix. 


MEMBRANOUS  DYSMENORRHCEA.  23^ 

regarding  its  causation.  While  it  is  not,  perhaps,  the  part  of  wisdom 
to  discredit  the  accepted  views  on  any  question  in  medicine  until  one 
has  souiething  more  reliable  to  offer,  still,  if  the  causes  assigned  can 
be  readily  shown  to  be  incorrect,  it  is  iniinitely  better  and  safer  to 
be  entirely  in  ignorance  of  the  causes  of  things  than  to  attribute 
them  to  the  wrong  causes.  Foi'tunately,  however,  while  I  find  my- 
self at  variance  with  most  of  the  recent  authorities  regarding  the 
cause  of  this  affection,  I  am  in  perfect  harmony  with  the  views  of 
Dr.  Oldham,  vvho  was  the  first  to  discover  "  dysmenorrhcea  mem- 
branacea." 

Dr.  Oldham  distinctly  pointed  out  the  characteristics  of  this  affec- 
tion, and  stated  that  the  membrane  is  formed  under  abnormal  ovarian 
stimulus ;  and  I  am  fully  satisfied  that  he  was  not  only  the  discoverer 
of  the  disease,  but  also  conceived  the  true  idea  regarding  the  cause  of 
it — viz.,  some  undue  ovarian  influence  or  sexual  excitation.  In  other 
words,  it  would  appear  to  be  some  derangement  of  innervation  and 
nutrition. 

Taking  this  view  of  the  causation,  I  expect  to  find  myself  in  har- 
mony with  the  neurologists  at  least.  This  class  of  specialists  mani- 
fests a  willingness  to  trace  many  diseases  originally  to  some  derange- 
ment of  the  nervous  system,  when  they  find  anything  like  good 
reasons  for  so  doing.  Hence,  I  expect  their  support  in  choosing,  as 
1  do,  to  believe  that  the  starting-point  in  the  pathology  of  this  affec- 
tion must  be  some  derangement  of  innervation  produced  by  disease 
or  functional  disturbance  of  the  ovaries.  Confirmation  of  this  view 
regarding  the  cause  of  membranous  dysmenorrhcea  may  be  found  in 
studying  the  agencies  which  give  rise  to  other  morbid  states  of  the 
uterus,  like  the  fibroid  growth,  for  example,  which  in  its  anatomical 
elements  does  not  differ  especially  from  the  tissues  of  the  uterus 
from  which  it  springs ;  and,  if  we  could  find  the  cause  of  this  devi- 
ation from  healthy  nutrition,  it  might  be  applicable  to  the  disease 
under  discussion.  But,  unfortunately,  the  causes  of  fibroid  tumors 
given  in  our  literature  are  unsatisfactory,  and  by  no  means  well  sus- 
tained. 

From  the  fact  that  uterine  fibroids  are  more  common  in  sterile 
women  than  in  others,  it  would  appear  that  sterility  predisposes  to 
their  development,  and  perhaps  no  better  explanation  of  the  cause  of 
these  growths  has  ever  been  given  than  that  of  my  somewhat  hu- 
morous friend,  who  said  that  "the  uterus,  being  prepared  for  normal 
work  and  not  finding  it  to  do,  took  up  the  development  of  fibroids 
as  a  sort  of  occupation  for  its  formative  powers."  May  it  not,  then, 
be  that  a  well-defined  predisposition  to  reproduction,  uncalled  for  by 


240  DISEASES   OF   WOMEN. 

gestation,  excites  this  morbid  action  on  the  part  of  the  uterus  which 
leads  to  this  abnormal  exfoliation  of  its  mucous  membrane  ?  This 
view  might  at  least  be  entertained,  because  in  other  cases,  when  we 
are  unable  to  detect  the  cause  of  a  disease  in  something  that  is  tan- 
gible, we  usually  attribute  it  to  deranged  innervation  and  conse- 
quent malnutrition.  This  view  of  the  causation  is,  to  some  extent, 
sustained  by  the  etfect  of  medicines  upon  the  lesions.  This  ailec- 
tio!i  has  always  been  recognized  as  one  that  is  often  difficult  to  cure, 
many  times  incurable,  in  the  hands  of  the  most  competent  phy- 
sicians and  surgeons.  This  possibly  may  have  been  due  to  misap- 
prehension of  the  nature  and  cause  of  the  disease,  and  hence  falla- 
cious therapeutics,  rather  than  to  the  incurable  character  of  the 
disease. 

In  favor  of  this  line  of  thought  I  may  state  that  the  patients 
whom  I  have  treated  in  years  ])ast,  on  the  theory  that  the  cause 
was  inflammatory,  have  derived  little  benefit,  while  those  who  were 
treated  for  deranged  innervation,  malnutrition,  and  undue  ovarian 
excitation,  have  made  very  much  better  progress.  I  am  inclined  to 
attribute  most  of  the  trouble  to  ovarian  influence,  the  condition  of 
the  ovaries  being  that  of  an  undue  nerve  excitation  and  possible 
congestion.  I  have  been  led  to  this  belief  by  two  facts :  that  the 
majority  of  the  patients  that  I  have  seen  have  been  subjects  of  a 
highly  nervous  organization,  and  in  most  of  them  there  has  been 
tenderness  of  the  ovaries,  and  pain  at  times,  without  there  being  any 
evidence  of  ovaritis. 

The  rheumatic  diathesis  is  said  to  favor  this  affection,  and  it  is 
possible  that  tliis  may  be  so,  although  I  am  unable  to  recall  any  of 
my  patients  as  l)eing  rheumatic ;  neither  have  I  been  able  to  trace 
it  to  the  tubercular  or  strumous  diathesis,  nor  to  syphilis.  It  is 
certain,  however,  that,  if  either  of  these  conditions  existed,  it  would 
have  its  influence  in  helping  to  keep  up  the  uterine  trouble,  and 
every  effort  should  therefore  be  made  to  relieve  it  by  treatment. 

Treatment. — The  treatment  of  this  affection  is  necessarily  both 
palliative  and  curative.  While  the  patient  is  suffering  during  the 
expulsion  of  the  membrane,  it  is  very  necessary  to  relieve  the  pain 
as  far  as  possible.  This,  of  course,  can  be  most  promptly  done  In 
the  use  of  opium,  which  should  be  avoided  if  jjossible,  however,  be- 
cause of  its  after-effects.  Sodimn  salicylate  and  antipyrine,  Ave 
grains  each,  may  be  given  when  the  stomach  is  empty. 

Chloral  hydrate  answers  fairly  well  in  some  cases.  I  am  not 
sure  that  it  has  any  advantages  over  chloroform,  camphor,  and 
belladonna,  or  conium  and  cannabis  Indica ;  in  fact,  in  the  major 


MEMBRANOUS   DYSMENORRHCEA.  241 

ity  of  cases  one  has  an  opportunity  to  try  several  agents,  and,  of 
course,  the  patient  will  decide  which  gives  most  relief.  Indications 
for  general  treatment  are  to  quiet  all  nervous  disturbance  and  to 
improve  the  general  nutrition  of  the  mucous  membrane.  It  so 
happens  that  when  the  first  part  is  attended  to  the  latter  will  follow 
in  due  order. 

To  quiet  the  nervous  irritation  and  disturbance  there  is  nothing 
that  equals  the  bromide  of  sodium.  This  should  be  given  in  twenty- 
or  thirty-grain  doses  three  times  a  day  for  ten  days  or  two  weeks 
before  the  menstrual  period.  And,  if  the  pain  is  not  severe  enough 
to  require  the  addition  of  some  of  the  remedies  already  named  to  re- 
lieve it,  the  bromide  may  be  continued  throughout  the  menstrual 
period  and  several  days  after.  From  this  it  would  appear  that  the 
bromide  is  to  be  used  continuously ;  but  one  or  two  weeks  in  each 
month  it  can  be  omitted.  When  the  bromide  has  been  employed 
for  some  time,  and  it  seems  desirable  to  give  it  up,  conium  may  be 
administered  in  moderate  doses  combined  with  camphor,  if  the  pa- 
tient is  weak.  If  there  is  any  evidence  of  the  rheumatic  diathesis, 
the  bromide  of  lithium  should  be  given.  Next  to  quieting  the  nerv- 
ous system,  any  debihty  that  may  exist  should  be  overcome  by  nerve 
tonics.  Undue  nervous  excitation  so  often  goes  hand  in  hand  with 
nervous  depression  that  in  many  cases  it  is  necessary  to  combine  the 
tonic  and  sedative  treatment.  All  the  remedies  which  may  be  used 
need  not  be  here  mentioned.  In  regard  to  the  modification  of  nu- 
trition, it  need  only  be  said  that  any  accompanying  derangements  of 
the  digestive  organs  that  may  be  found  should  receive  careful  atten- 
tion ;  but  this  hardly  need  be  mentioned  in  this  connection. 

My  rule  of  treatment  has  been,  after  subduing  all  nervous  dis- 
turbances, to  put  the  patient  upon  the  iodide  of  sodium  in  case  she 
is  in  fair  strength  and  inclined  to  flesh.  If  there  is  anaemia,  I  prefer 
the  iodide  of  iron.  If  these  do  not  accomplish  the  object,  I  employ 
mercury,  giving  it  in  small  doses,  never  continuing  it  long  enough 
to  produce  salivation,  carefully  watching  to  avoid  this.  In  cases  of 
aneemia,  where  I  have  feared  the  debiEtating  eifect  of  this  alterative, 
I  have  given  the  bichloride  of  mercury  with  iron.  After  keeping 
them  upon  this  treatment  until  I  could  see  some  evidence  of  its 
effects,  I  have  then  put  them  upon  iodine  and  arsenic. 

In  regard  to  local  treatment,  I  have  been  entirely  guided  hy  the 
^niews  of  the  pathology  as  expressed  above,  and  have  therefore  em- 
ployed alteratives  and  sedatives  almost  exclusively.  Of  these  I  have 
found  iodoform  most  effectual.  I  have  also  used  iodine  and  mer- 
cury with  advantage.     In  cases  where  I  have  found  any  complications 


242  DISEASES  OF    WOMEN. 

I  have  carefully  attended  to  them,  restoring  displacements  and  cor- 
recting flexions,  and  so  on.  When  the  canal  has  been  constricted, 
free  dilatation  and  jjacking  with  gauze  have  been  efficient. 

"When  the  congestion  which  occurs  at  the  menstrual  period  has 
not  subsided  in  a  few  days,  I  have  employed  the  warm-water  douche. 
After  this,  1  have  applied  to  the  cavity  of  the  uterus  small  bougies 
of  cocoa-butter  with  as  much  iodoform  as  they  would  take  up.  Three 
or  four  grains  of  iodoform  mixed  with  vaseline  that  has  been  lique- 
fied by  heat,  and  introduced  through  the  pipette,  is  perhaps  the  best 
method  of  applying  it.  This  has  been  introduced  once  a  week  or 
once  every  live  days.  When  there  has  been  much  tenderness,  and 
the  use  of  the  pencils  has  caused  pain,  I  formerly  used  aconite  and 
opium  and  iodine ;  this  I  have  introduced  into  the  cavity  of  the 
uterus.  I  am  now  trying  cocaine  to  subdue  the  tenderness  as  a  pre- 
paratory means  to  the  use  of  the  iodoform.  But  so  far  this  new 
remedy  has  not  been  a  perfect  success. 

In  cases  where  this  has  failed  and  the  uterus  was  not  especially 
sensitive  to  intra-uterine  medication,  I  have  instilled  into  the  uterine 
cavity  a  few  di'Oj)s  of  a  S-jDer-cent  solution  of  carbolic  acid,  making 
one  application  a  few  days  after  the  menstrual  flow  and  not  repeat- 
ing it  until  the  next  period.  In  the  interval  I  have  used  the  iodo- 
form. I  have  also  used  the  fluid  extract  of  conium  and  hydrastis 
Canadensis  ;  but  this  I  have  found  gives  more  pain  than  any  of  the 
other  applications  that  I  have  used ;  and  so  of  late  I  liave  used  an 
infusion  of  the  hydi'astis  alone,  which  appears  to  answer  as  well  and 
gives  less  pain. 

HISTORY    OF    CASES. 

Case  I.  Membranous  Lysmenorrhcea  in  a  Married  Lady  who  was 
never  Pregnaat. — This  patient  was  forty-one  years  of  age,  of  good 
constitution,  and  had  been  married  eight  years.  She  began  to  men- 
struate at  thirteen,  and  continued  to  do  so  regularly  and  normally 
until  slie  was  twenty-one ;  then  she  began  to  have  occasional  pain, 
about  the  menstrual  ])eriod,  in  the  region  of  the  ovaries.  About  a 
year  after  this  she  began  to  have  severe  uterine  pains  during  the 
menses,  and  states  that  she  occasionally  passed  masses  that  looked 
like  membrane  fi'om  the  uterus;  they  were  small,  however,  and  did 
not  apjiear  at  each  period. 

After  her  marriage  the  pain  at  the  menstrual  periods  became 
worse,  and  almost  every  month  she  passed  a  membi'anous  cast  of  the 
uterus.  The  usual  history  of  each  menstruation  is  that  the  flow  he- 
gins  not  very  free,  and,  after  continuing  for  about  five  hours,  the 
pain  becomes  very  intense  and  lasts  from  three  to  eight  hours,  when 


MEMBRANOUS   DYSMENORRUCEA.  243 

she  expels  the  membrane  and  the  pain  subsides,  the  flow  continuing 
for  a  day  or  a  day  and  a  half  after  the  membrane  has  been  expelled. 

The  flow,  taken  altogether,  is  not  profuse,  and  only  lasts  from 
two  to  two  and  a  half  days,  while  formerly — that  is,  before  her  dys- 
menorrhoea  began — it  used  to  continue  from  four  to  Ave  days.  When 
flrst  seen,  her  general  health  was  good,  but  she  was  rather  hysterical 
and  nervous,  and  was  somewhat  depressed  and  disappointed  because 
she  had  not  had  children. 

She  described  the  suffering  at  her  menstrual  periods  as  some- 
thing unbearable,  although  it  did  not  last  more  than  a  few  hours  at 
a  time.  She  was  flrst  examined  midway  between  the  menstrual 
periods.  The  uterus  was  then  found  to  be  normal  in  size  and  in 
good  position.  The  internal  os  was  rather  sensitive  and  appeared 
to  be  slightly  contracted ;  there  was  also  a  distended  Nabothian 
gland  in  the  middle  third  of  the  cervical  canal,  but  the  uterus  pre- 
sented a  normal  appearance  in  every  other  respect.  There  was  no 
congestion  ;  in  fact,  at  this  time  the  mucous  membrane  appeared 
rather  anaemic. 

The  diagnosis  was  left  an  open  question  until  the  next  menstrual 
period,  when  I  obtained  the  membrane  expelled  and  had  it  examined 
by  my  friend  Professor  Frank  Ferguson.  His  report  stated  that  the 
specimen  was  uterine  mucous  membrane  unchanged  in  its  histological 
composition.     This  settled  the  question  of  diagnosis. 

Careful  inquiry  elicited  the  fact  that  she  had  never  been  preg- 
nant, so  far  as  I  could  rely  upon  her  testimony,  which  I  believe  to 
be  accurate  because  of  her  great  desire  to  have  children.  I  also 
learned  that  on  several  occasions  she  had  lived  apart  from  her  hus- 
band, who  was  of  necessity  absent  on  business  for  several  months  at 
a  time,  and  that  she  suffered  just  the  same,  and  at  each  month  there 
was  an  expulsion  of  membrane,  showing  conclusively  that  there  was 
no  possibility  of  mistaking  this  affection  for  pregnancy  and  abortion. 

The  ti-eatment  consisted,  flrst,  in  placing  her  upon  the  following- 
mixture  :  Half  a  grain  of  the  bichloride  of  mercury,  one  drachm  of 
the  solution  of  the  chloride  of  arsenic,  three  drachms  of  the  tincture 
of  iron  in  a  three-ounce  mixture  of  sirup  and  water.  A  teaspoonful 
of  this  was  given,  well  diluted,  after  each  meal.  At  the  same  time 
the  internal  os  was  incised  superflcially  in  three  places,  dividing 
equally  the  circumference  of  the  canal,  and  the  distended  ISTabothian 
follicle  was  punctured  and  evacuated. 

A  week  after  this  a  sound  was  introduced  of  full  size,  and  there 
was  less  tenderness ;  the  tincture  of  iodine  was  then  a]:)plied  from 
just  within  the  internal  os  outwai-d.     At  the  next  menstrual  period 


2-I-4  DISEASES   OF   WOMEN. 

she  had  less  pain,  but  it  lasted  just  as  long,  and  she  passed  a  mem- 
brane uuchanged,  except  that  it  did  not  appear  so  thick  as  formerly. 

From  this  onward  the  local  treatment  consisted  in  passing  a  full- 
sized  sound  just  beyond  the  internal  os  directly  after  the  menstrual 
period,  and  again  in  two  weeks,  and  in  nearly  every  six  days  about 
two  grains  of  iodoform  mixed  with  vaseline  were  passed  into  the  cav- 
ity of  the  uterus,  well  up  toward  the  fundus.  This  local  treatment 
was  continued  without  interruption  for  three  months,  and  the  iirst 
prescription,  after  it  had  been  taken  for  two  wxeks,  was  followed  by 
the  iodide  of  iron,  a  grain  and  a  half  three  times  a  day. 

After  the  second  month,  and  at  the  third  menstrual  period  from 
the  time  that  treatment  began,  she  had  no  pain  and  passed  no  mem- 
brane. At  the  next  period  she  passed  several  shreds,  but  nothing 
like  a  complete  cast  of  the  uterus. 

The  constitutional  treatment,  that  is,  alternating  between  the  first 
prescription  of  mercury  and  arsenic  and  the  iodide  of  iron,  giving 
first  one  for  two  weeks,  and  then  the  other,  was  continued  for  two 
months  longer.  The  application  of  the  iodoform  was  continued 
for  one  month  longer,  once  every  week,  and  once  after  her  menstru- 
ation, at  the  end  of  the  fourth  month  of  the  treatment.  Since  that 
time  she  has  had  no  further  trouble ;  her  menses  are  regular,  lasting 
about  three  days,  and  entirely  without  pain  or  any  discharge  of 
membrane. 

That  was  her  record  at  least  one  year  after  she  gave  up  treatment, 
since  which  time  I  have  not  heard  from  her. 

Cast:  11.  Membranous  Dysmenorrhoea  occurring  after  Treatment 
for  Anteflexion  and  One  Miscarriage. — A  lady  of  very  high  culture 
and  over-refinement,  of  a  well-marked  nervous  temperament,  but 
otherwise  of  good  constitution,  came  under  my  observation  when 
twenty-eight  years  of  age ;  she  had  then  been  married  a  year  and  a 
half.  She  menstruated  first  at  fourteen  years,  and  continued  to  do 
so  regulai'ly,  but  with  pain  from  the  very  l)eginning.  The  pain 
usually  began  a  day  or  so  before  the  flow  and  gradually  diminished 
after.  Her  suffering  at  each  period  gradually  increased  until  her 
marriage,  when  it  l)ecame  more  severe.  This,  and  the  fact  that  she 
remained  sterile,  induced  her  to  seek  advice.  I  found  her  suffering 
from  anteflexion  of  the  body  of  the  uterus  and  cervical  endometritis ; 
there  was  also  tenderness  of  the  left  ovary  on  pressure.  She  was 
treated  for  the  flexion,  and  completely  recovered.  The  dysmenor- 
rhoea  was  entirely  relieved,  and  she  became  pregnant.  During  her 
pregnancy  she  suffered  very  much  from  morning  sickness,  and  at 
the  end  of  the  third  month   began  to  show  some  signs  of  septi- 


MEMBRANOUS  DYSMENORRIICEA.  245 

coemia;  she  then  miscarried,  and  the  ovum  was  found  to  be  macer- 
ated, and  probably  had  been  dead  in  uUro  for  two  weeks.  She 
recovered  from  this  and  was  quite  well  for  about  a  year,  when  her 
dysmenorrlujea  returned ;  she  then  returned  to  be  treated  for  wliat 
she  supposed  to  be  a  recurrence  of  her  former  trouble,  but  I  found 
no  evidence  of  the  former  flexion.  But,  on  inquiry,  I  found  that 
she  passed  at  each  period  a  membranous  cast  of  the  uterus.  The 
patient  thought  little  of  this,  because  in  former  years,  while  suffering 
from  the  dysmenorrhoea  caused  by  flexion,  she  occasionally  passed 
small  clots  which  looked  somewhat  membranous  in  character,  but  no 
doubt  were  simply  blood-clots. 

She  was  placed  upon  treatment  similar  to  that  employed  in  the 
lirst  case  reported,  except  that  there  was  no  necessity  for  enlarging 
the  internal  os  as  in  the  former  case,  the  only  difference  in  the  local 
treatment  being  that  I  used  iodine  in  place  of  iodoform  during  the 
last  two  months  of  the  treatment ;  and  once,  immediately  after  the 
menstrual  period,  I  applied  a  mild  solution  of  carbolic  acid  to  the 
uterine  cavity. 

She  did  not  again  pass  any  membrane  after  the  third  month  of 
treatment,  and  her  pain  from  menstruation  entirely  disappeared. 

She  was  dismissed  at  the  end  of  four  months,  and  two  months 
afterward  reported  that  she  was  pregnant.  Three  months  after  that 
time  she  was  examined  and  found  to  be  so,  and  was  progressing  well. 
Since  that  time  I  have  not  seen  her,  but  have  heard  that  she  gave 
birth  to  a  healthy  child. 

Case  III.  Membranous  Dysmenorrhoea  treated  by  Dr.  Fordyce 
Barker,  of  New  York;  Complete  Recovery. — I  give  the  history  of  the 
following  case  for  two  reasons :  First,  to  show  that  iodoform  was 
employed  in  the  local  treatment,  and  that  the  patient's  recovery  was 
complete ;  and  also  to  take  the  opportunity  of  stating  that  I  believe 
that  Dr.  Barker  was  the  flrst  to  employ  this  agent. 

The  history  is  not  altogether  complete,  because  I  obtained  it  from 
the  patient  herself,  who  was  unable  to  tell  all  that  was  done  for  her; 
but  I  know  positively  that  slie  suffered  from  dysmenorrhoea,  and  that 
she  entirely  recovered  under  the  care  of  Dr.  Barker,  and  has  remained 
well  for  a  number  of  years. 

This  was  an  educated  lady  of  a  well-marked  nervous  temperament ; 
she  began  to  menstruate  at  thirteen,  and  continued  to  do  so  normally 
until  she  was  twenty-six  years  of  age.  At  that  time  she  was  said  to 
have  had  an  acute  attack  of  ovaritis,  and  after  recovering  from  that 
she  had  dysmenorrhcea. 

The  character  of  the  pain  at  her  menstrual  periods  then  appeared 


246  DISEASES  OF  WOMEN. 

to  be  ovarian.  After  suffering  in  this  manner  for  about  four  or  live 
years  she  noticed  the  expulsion  of  membranous  casts  of  the  uterus 
at  the  menstrual  periods.  During  this  time  and  for  a  year  afterward 
she  was  regularly  treated  l)y  her  family  physician,  but  without  relief. 
She  then  consulted  Dr.  Barker  for  her  general  ill-health,  but  did  not 
call  his  attention  to  her  derangement  of  the  menstrual  function. 
She  improved  in  her  general  condition  under  his  care,  but  found  no 
relief  from  the  memljranous  menstruation.  She  consulted  him  again 
and  called  his  attention  to  the  uterine  trouble,  and  he  immediately 
placed  her  under  treatment. 

The  constitutional  remedies  employed  I  do  not  know,  but  the 
local  treatment  consisted  in  dilatation  of  the  cervical  canal  and  the 
application  of  iodoform  to  the  uterine  cavity. 

She  continued  to  pass  membrane  for  several  months ;  then  the 
trouble  ceased,  and  has  not  returned.  She  now  menstruates  regularly 
and  naturally,  and  has  done  so  for  over  two  years. 

Several  other  cases  might  be  added,  some  showing  failure  of 
treatment,  and  others  where  the  patients  were  really  made  worse  l)y 
being  treated  for  inflammation  of  the  uterus  which  w^as  supposed  to 
be  the  cause  of  the  affection,  but  undoubtedly  was  not.  Other  cases 
might  be  given,  also,  in  which  recovery  took  place,  and  after  several 
months  or  years  the  trouble  returned,  but  they  would  add  nothing 
to  the  views  already  expressed  regarding  the  pathology  and  treat- 
ment of  this  affection. 


CHAPTER  XIV. 

LACEKATIONS  OF  THE  CERVIX  UTERI. 

Regarding  this  subject  Dr.  Thomas  Addis  Emmet  says :  "  Its 
importance  can  not  be  exaggerated,  since  one  half  of  the  ailments 
among  those  who  have  borne  children  are  to  be  attributed  to  lacera- 
tions of  the  cervix." 

This  estimate  of  the  frequency  and  consequences  of  laceration 
of  the  cervix  uteri  is  quite  sufficient  to  introduce  the  subject  and 
secure  for  it  special  attention. 

Sir  James  Y.  Simpson  pointed  out  the  fact  that  lacerations  of 
the  cervix  uteri  frequently  occurred,  and  Dr.  Gardiner  also  described 
such  lesions  and  their  results  ;  but  to  Dr.  Emmet  is  due  the  credit 
of  describing  fully  the  pathology  of  lacerations  of  the  cervix  and 
their  causative  relations  to  many  other  uterine  diseases.  He  also 
devised  efficient  surgical  means  for  their  relief.  This  is  certainly 
the  most  brilliant  of  all  Dr.  Emmet's  achievements. 

The  disturbing  influences  of  this  injury  upon  the  sexual  organs 
and  the  general  health  are  usually  marked,  but  depend  to  some 
extent  upon  the  magnitude  and  location  of  the  laceration.  The  first 
eifect  noticed  is  to  retard  recovery  after  confinement.  The  lacera- 
tion exposes  raw  surfaces  to  the  lochial  discharges  which,  when 
these  are  decomposing  and  offensive,  may  give  rise  to  septicaemia. 
Even  where  this  does  not  occur  the  injury  interrupts,  more  or  less, 
the  process  of  involution  and  produces  all  the  troubles  which  usu- 
ally follow  therefrom. 

There  is  more  or  less  inflammatory  action  set  up  in  the  parts, 
and  the  efforts  at  healing  the  laceration  develop  much  scar  tissue 
and  not  unfrequently  enlargement  and  hardening  of  the  parts  fi'ora 
areolar  hyperplasia.  The  scar  tissue  thus  formed  and  the  sclerosed 
tissues  beneath  and  around  the  scars  are  often  tender  and  painful. 
All  this  proves  to  be  a  source  of  local  irritation,  and  sometimes 
causes  much  general  disturbance  through  reflex  action.     The  inflam- 

247 


248  DISEASES   OF   WOMEN. 

matory  action  which  immediately  follows  the  injury  does  not  entirely 
subside  when  cicatrization  is  complete.  The  inflammation  in  the 
cervical  mucous  membrane  lingers  there,  and  hence  old  lacerations 
are  generally  accompanied  with  marked  catarrh  of  the  cervical  mem- 
brane. This  is  kept  up  and  often  aggravated  by  the  eversion  or 
rolling  outward  of  the  divided  walls  of  the  cervix,  which  exposes 
the  cervical  mucous  membrane  to  fiiction  and  the  acid  secretions  of 
the  vagina.  Therefore,  the  cervical  endometritis  accompanying 
lacerations  has  no  natural  tendency  to  disappear.  It  is  also  rebel- 
lious to  treatment,  and  finally,  if  it  is  subdued,  it  soon  returns  unless 
the  original  injury  is  repaired.  In  lacerations  of  long  standing,  and 
especially  those  that  have  been  treated  by  caustics,  the  mucous  folli- 
cles become  closed  and  distended,  assuming  the  form  of  small  cysts. 
The  presence  of  these  distended  cysts  increases  the  size  of  the  cer- 
vix and  gives  an  irregular  outline  to  the  surfaces  under  which  they 
are  situated.  By  pressure  they  cause  absorption  of  the  tissues  of  the 
cervix,  so  that  when  they  are  punctured  or  ruptured  and  their  con- 
tents are  evacuated  the  cervix  becomes  diminished  below  the  original 
size. 

The  several  forms  of  laceration  of  the  cervix  uteri  most  fre- 
quently seen  in  practice  are  : 

1.  Lateral  lacerations  of  one  or  both  its  walls. 

2.  Antero-posterior  laceration  ;  usually  found  in  the  posterior 
wall,  but  occasionally  involving  botli. 

3.  Multiple  lacerations,  usually  three  in  number,  but  occasionally 
more. 

4.  Incomplete  lacerations,  in  which  the  solution  of  continuity 
extends  from  within  outward  through  the  mucous  membrane  and 
muscular  walls  of  the  cervix,  but  not  through  the  mucous  membrane 
of  the  vagina.  This  form  of  injury  is  generally  bilateral,  but  occa- 
sionally the  lacerations  are  multiple,  involving  the  two  walls  laterally 
and  the  posterior  and  anterior  walls  also. 

Sometimes  two  of  these  forms  of  injury  are  found  together,  as, 
for  example,  a  complete  bilateral  laceration  and  an  incomplete  lacer- 
ation of  the  anterior  wall  of  the  cervix. 

The  first,  and  by  far  the  most  common  of  these  injuries,  lateral 
laceration,  presents  several  varieties.  The  bilateral  laceration,  in  its 
typical  form,  divides  the  cervix  into  two  equal  parts,  and  extends  up 
to  the  vaginal  junction. 

As  seen  at  times,  the  laceration  is  superficial,  extending  not  more 
than  half  way  up  to  the  vaginal  junction  ;  again,  the  laceration  may 
extend  on  one  side  up  above  the  vaginal  junction,  while  on  the  other 


LACERATIONS   OF   THE   CERVIX   UTERI. 


249 


Fig.  109.- 


it  is  mucli  less  extensive.     In  other  cases  the  bilateral  laceration 
divides  the  cervix  into  two  unequal  parts,  the  anterior  portion  usu- 
ally being  tlie  larger 
(Fig.  109). 

The  morbid  states 
of  the  cervix  uteri 
which  accompany 
this  form  of  injury 
and  are  caused  by  it 
vary  greatly.  In  the 
simplest  forms  the 
cervix,  in  the  aggre- 
gate, is  not  much  en- 
larged ;  the  divided 
halves  rest  nearly  to- 
gether, and  protect 
the  mucous  mem- 
brane of  the  cervi- 
cal canal.  Under 
these  circumstances 
a  slight  hypersemia 
of  the  cervical  mu- 
cous membrane  and  a  slight  leucorrhoea  are  all  the  lesions  present  in 
many  cases.     Even  these  are  not  always  found. 

In  other  cases  the  halves  of  the  cervix  are  widely  separated. 
The  mucous  membrane  of  the  canal  is  everted,  and  is  generally  de- 
nuded of  its  epithelium,  markedly  congested,  often  thickened  and 
irregular,  and  covered  with  a  profuse  leucorrhoeal  discharge.  In  still 
other  cases  there  is,  in 
addition  to  the  above 
e version,  a  marked  hy- 
perplasia of  all  the  tis- 
sues, especially  on  the 
inner  surfaces.  The 
new  tissue  fills  in  the 
space  between  the 
halves  of  the  cervix,  so 
that  the  opposite  sides 
of  the  laceration  can 
not  be  brought  togeth- 
er (Fig,  110). 

„,^.  ,         -  Fig.  110. — Bilateral  laceration,  with  thickening  of  the 

llus      SUperabund-  everted  lips. 


-Bilateral  laceration ;  unequal  division  of  the 
cervix. 


250 


DISEASES   OF   WOMEN. 


ant  tissue  is  produced  by  arrest  of  involution  and  areolar  hyperplasia. 

The  tissue  is  denser  than  normal,  and,  in  fact,  presents  a  trne  sclerosis. 

^_____  Lacerations   of  the    an- 

tero  -  posterior  walls,  while 
they  are  said  by  Emmet 
to  occur  frequently,  are 
comparatively  less  often 
seen,  because  they  generally 
heal  promptly  and  com- 
])letely  of  their  own  accord. 
Where  they  are  found,  they 
are  generally  complicated 
with  all  the  lesions  de- 
scribed in  connection  with 
lateral  injuries. 

Multiple  lacerations  vary 
greatly  in  number  and  ex- 
tent. A  trilateral  laceration 
is  most  frequently  met  with. 
The   cervix   is   usually   di- 


FiG.   111. — Extensive  multijjle  lacerations. 


vided  into  three  unequal  parts,  as  seen  in  Fig.  111. 

This  may  be  called  a  complete  multiple  laceration,  because  all 
the  tissues  of  the  cervix  are 
divided.  There  is  another 
form  of  tins  injury  in  which 
there  are  a  number  of  lacer- 
ations which  extend  from 
within  outward,  but  do  not 
involve  the  vaginal  mucous 
membrane  (Fig.  112). 

The  lateral  incomplete  lac- 
eration may  be  unilateral  or 
bilateral.  CTenerally,  both 
walls  are  divided  from  within 
outward  to  the  outer  mucous 
coat.  This  injury  is  over- 
looked quite  often  by  gynecol- 
ogists. At  least,  I  infer  this 
from  the  fact  that  Dr.  Em- 
met is  the  only  writer  of  all 
those   whose    works    I    have 

consulted  who  mentions  it.  Fi,;.   il2.— Multii)lc  incomplete  lacerations. 


LACERATIONS   OF   THE   CERVIX   UTERI. 


251 


Fig.  113. — Incomplete  bilateral  laceration. 


It  is  usually  described  as  a  patulous  or  dilated  condition  of  tlie 
cervix,  and  to  the  toucli  and  inspection  it  appears  to  be  so,  but  a 
careful  examination  shows  that  the  cei"vix  is  divided  into  two  parts 

that  are  held  together  by  the 
outer  coat,  or  mucous  membrane. 
Fig.  113  shows  the  lesion. 

This  lesion  can  be  most  con- 
veniently demonstrated  by  pass- 
ing the  uterine  sound  into  the 
cervical  canal,  and  then  carrying 
it  outward  in  the  line  of  the 
laceration,  when  it  will  become 
apparent  that  the  outer  coat  of 
the  cervical  wall  is  all  that  re- 
mains intact.  There  is  usually 
no  e version  of  the  mucous  mem- 
brane, but  almost  always  there 
is  a  marked  catarrh  of  this  membrane,  which  is  peculiarly  resistant 
to  treatment.  In  a  number  of  these  cases  I  have  found  enlargement 
of  the  anterior  half  of  the  cervix  whicli  gave  a  crescentic  appearance 
to  the  OS  externum,  Fig.  115. 

Causation.  —  Laceration  of 
the  cervix  is  usually  cansed  by 
parturition,  either  natural  or  in- 
strumental. In  a  great  majori- 
ty of  first  labors  the  cervix  is 
injured  to  some  extent,  but  in 
many  the  laceration  either  unites 
or,  being  very  superficial,  gives 
no  trouble  and  passes  unnoticed. 
Certain  conditions  of  the  tissues 
of  the  cervix  predispose  to  lac- 
eration. Irregular  development 
of  the  cervix  either  before  or 
during  pregnancy,  in  which  one 
wall  is  thicker  than  the  other ; 
induration  from  previous  dis- 
ease, which  lessens  the  elasticity 

of  the  tissues ;  and  a  softened  a?dematous  condition  of  the  cervixj 
produced  by  pressure  in  tedious  labors— all  these  favor  laceration. 

In  abnormal  labors  requiring  manual  and  instrumental  aid  be- 
fore the  cervix  is  dilated  there  is  additional  liability  to  injury,  and 


Fig.  114. — The  incomplete  bilateral  lacera- 
tion shown  in  Fig.  113,  as  seen  by  sec- 
tion of  the  cervix. 


252 


DISEASES   OF  WOMEN. 


y^.MiM4i^^ 

A 

^^■' ,  :;,,.  jw:*^f?P^ 

i 

■w 

this  frequently  occurs ;  but  it  is  also  a  fact  that  lacerations  often  take 
place  in  perfectly  easy  and  natural  labors.  Indeed,  it  appears  that 
in  easy  and  rapid  labor  lacer- 
ations are  very  likely  to  oc- 
cur, such  frequently  showing 
that  precipitate  delivery  is  a 
cause  of  this  accident.  Dr, 
Emmet  states  in  his  book 
that  he  has  seen  laceration 
of  the  cervix  in  cases  of 
criminal  abortion.  I  have 
never  seen  laceration  of  the 
cervix  after  abortion  from 
any  cause  at  or  before  the 
third  month  of  gestation. 
There  is  a  condition  of  en- 
largement of  the  cervix  with 
eversion  of  the  mucous  niem- 
braue  of  the  cervical  canal 
which  presents  all  the  phys- 
ical signs  of  a  superficial 
bilateral  laceration,  and  this 

I  have  seen  after  abortion  in  the  first  pregnancy,  but  I  have  also  seen 
the  same  condition  in  the  virgin  uterus.  This  alfection  is  described 
under  the  head  of  cervical  endometritis,  and,  therefore,  need  not  be 
discussed  here. 

From  what  has  been  said,  it  will  appear  certain  that  this  injury 
can  not  at  all  times  be  prevented  by  any  skill  and  care  on  the  part  of 
the  obstetrician.  This  should  always  be  borne  in  mind  and  freely 
stated  where  the  injury  is  attril)uted  to  carelessness  on  the  part  of 
the  attendant  during  lalxjr,  a  mistaken  criticism  not  unconnnonly 
heard  anions  the  laitv. 

The  effect  of  this  injury  n\)(m  the  uterus  and  the  general  health 
of  the  patient,  together  with  the  symptoms  and  physical  signs,  will  be 
brought  out  in  full  in  the  histories  ofi  llustrative  cases  which  follow. 

The  treatment  of  tliis  injury  includes  the  j)rimary  and  secondary 
management.  It  has  been  suggested  that  when  the  injury  takes 
place  the  laceration  should  be  immediately  clossd  with  sutures,  but 
this  is  impracticabk'.  First,  because  it  is  impossible  to  fully  estimate 
the  extent  of  a  laceration  in  the  relaxed  condition  of  the  cervix  im- 
mediately after  delivery ;  and,  secondly,  the  difficulty  of  accurate- 
ly adjusting  sutures  under  the  circumstances  would  subject  the  pa- 


FiG.   115. — Crescentic  laceration. 


LACERATIONS   OF   THE   CERVIX   UTERI.  253 

tient  to  exposure,  wliicli  is  unwarranted.  Besides  this,  the  intro- 
duction of  sutures  and  the  disturbance  of  the  tissues  necessary  to 
their  introduction  would  tend  to  interfere  with  spontaneous  union, 
a  favorable  termination  not  infrequently  attained.  The  primary 
treatment  then  must  be  limited  to  the  usual  means  employed 
by  the  competent  obstetrician  to  secure  noi'raal  involution  of  the 
pelvic  organs.  The  secondary  treatment  should  embrace  three 
objects  :  First,  to  overcome  the  consequences  of  the  injury  ;  sec- 
ond, to  improve  the  nutrition  of  the  parts  injured,  and  thus  pre- 
pare them  for  the  third  step,  the  repair  of  the  laceration  by  surgical 
means. 

When  an  improvement  in  the  condition  of  the  tissues  of  the 
uterus  is  attained,  the  general  health  of  the  patient  is  usually  bene- 
lited  by  securing  the  best  conditions  for  success  in  the  operation 
for  restoring  the  laceration.  In  order  to  do  this  it  is  necessary  to 
overcome  as  far  as  can  be  the  endometritis  which  usually  accompa- 
nies the  injury.  The  means  used  for  this  purpose  sometimes  suc- 
ceed in  relieving  the  subinvolution  which  usually  is  present  in  those 
cases.  Where  there  is  much  enlargement  of  the  cervix  from  areolar 
hyperplasia,  which  makes  it  impossible  to  bring  the  divided  edges 
together,  and  all  ordinary  treatment  fails  to  reduce  this  enlargement, 
it  is  sometimes  necessary  as  a  prej)aratory  measure  to  remove  a  por- 
tion of  the  tissue  on  the  inner  sides  of  the  divided  halves  of  the  cer- 
vix and  allow  the  parts  to  heal  before  performing  the  final  opera- 
tion. This  I  have  usually  accomplished  by  taking  out  a  section  on 
each  inner  side  of  the  halves  and  bringing  them  together  with  a 
couple  of  sutures.  These  are  left  in  place  for  a  week  or  two,  and  in 
the  mean  time  the  hot-water  douche  should  be  used,  and  such  local 
applications  as  may  be  necessary  to  relieve  catarrh  or  hyper^emia. 
The  sutures  are  then  removed,  and  after  a  few  weeks  the  operation 
for  the  restoration  of  the  cervix  is  performed.  When  there  are  a 
number  of  cysts  in  the  cervix  (a  condition  known  as  cystic  degenera- 
tion) they  should  all  be  opened  and  evacuated.  Sometimes  the 
everted  mucous  membrane  becomes  very  much  thickened,  and  pre- 
sents a  granular  or  papillomatous-looking  surface.  When  such  is  the 
case,  it  is  best  to  trim  off  the  more  prominent  points  on  the  surface, 
and  subsequently  make  such  application  as  will  reduce  the  thicken- 
ing and  vascularity  of  the  membrane. 

It  has  been  suggested  by  some  that  whenever  there  is  a  laceration 
it  should  be  at  once  restored.  Such  authorities  are  of  the  opinion 
that  if  the  operation  is  successful  the  other  pathological  lesions  which 
were  caused  originally  by  it  will  disappear  eventually.     This  is  not 


254  DISEASES   OF   WOMEN. 

by  any  means  to  be  relied  upon,  and  I  much  prefer  to  remove,  as  far 
as  possible,  all  local  complications  before  operating. 

The  objects  to  be  obtained  b}'  the  operation  are  to  remove  the 
scar  tissue  formed  by  the  healing  of  the  ununited  edges  of  the  lacer- 
ation, and  thereby  relieve  the  pain  and  reflex  disturbances  which 
it  may  have  given  rise  to,  and  also  to  close  in  the  mucous  mem- 
brane and  protect  it  from  further  irritation.  There  is  still  an- 
other important  benefit  gained  by  the  operation — viz.,  when  the 
uterus  is  larger  than  normal,  owing  to  subinvolution,  a  marked 
reduction  in  its  size  will  follow  after  this  operation.  I  beheve 
that  the  completion  of  involution  generally  follows  successful  res- 
toration of  the  cervix,  excepting  in  those  who  have  had  puei-peral 
metritis. 

In  recent  superficial  lacerations  I  have  operated  without  anaes- 
thetizing the  patient.  The  pain  of  the  operation  is  trivial  compared 
with  the  distress  from  the  after-effects  of  an  anaesthetic.  As  a  rule, 
however,  it  is  necessary  to  administer  an  anaesthetic,  especially  in 
deep  lacerations  of  long  standing,  where  there  is  much  scar  tissue 
and  consequent  tenderness. 

The  operation  for  the  restoration  of  the  cervix  uteri  must  vary 
a  little  in  detail  according  to  the  nature  of  each  form  of  injury, 
but  the  operation,  as  performed  on  the  bilateral,  uncomplicated 
form  of  laceration,  illustrates  in  the  most  perfect  way  the  mech- 
anism and  details  of  the  operation.  I  will,  therefore,  describe 
the  operation  in  this  form  of  laceration,  and  give  cases  the  histo- 
ries of  which  will  illustrate  the  necessary  modifications  in  the  other 
forms. 

The  operation  is  performed  as  follows :  The  patient  is  placed 
upon  the  left  side,  and  a  Sims's  speculum  introduced  and  held  by 
a  trained  nurse  or  assistant.  A  tenaculum  forceps,  curved  upon  the 
flat  side,  is  fixed  in  the  anterior  half  of  the  cervix,  at  the  point  which 
makes  the  lip  of  the  os  externum.  The  posterior  half  of  the  cervix 
is  seized  in  the  same  way  with  a  similar  forceps,  and  the  operator, 
taking  a  forceps  in  each  hand,  brings  the  two  flaps  together,  in 
order  to  see  exactly  where  the  parts  are  to  be  united.  The  forceps 
which  holds  the  anterior  flap  is  then  given  to  an  assistant,  while 
the  one  attached  to  the  posterior  flap  is  held  in  the  left  hand  of  the 
operator,  and  the  surfaces  ai"e  denuded  by  the  hawk-bill  scissors.  Fig. 
IIP). 

The  points  of  the  scissors  are  made  to  seize  the  angle  formed  by 
the  junction  of  the  two  flaps  as  far  up  as  appears  necessary  to  denude 
them.     The  flaps  are  brought  together  by  the  aid  of  the  forceps  on 


PLATE  I. 


FIG. 117 
PAGE  255. 


FIG. 120 
PAGE  258. 


FIG. 121 
PAGE  258. 


R.L. D.DEL 


riug  tit 


witiiii 


The  blades  of  tL 


^^^^jjsijtte** 


'/•ic'  .-^-Z'>*. 


\ 


"'^'S*^^ 


the  sail 
pleted. 


d  the  most 


PLATE  I. 

i 


)n  ifi  cmii- 


Operation.for  Lacekation  of  the  Cervix  Uteri, 


sides  "h"^ 

Figure  117.     Page  355. 


i:>u  iijK 

easily  ' 

sci^jsons  ,,      uvPenudation  complete. 

the  iiniii  ■  a!i'''^'>  of  thc^ 

111'  che  op; 

-\\u\      .  ■'"■  1 "    Figure  120.     Page  258. 

^  .  '  ,  •  ,  ■  1     The  sutures  in  position. 

tiuUti    of    til"    ■■'■'     ..---'■■I      ■       .,v.....    ,.M     ',      A, 

cmvince  u.  ^.        .o-.     t.       ^^o 

Figure  121.     Page  258. 
tissue  can  not  be  rt- 1 

ti^o+   T  . .,.,  ....   ,1,,.,    ,ThQ  sutures  tied. 
■^'vTi  ire  ii'ood  ITT'- 

I  ii:.  ii7,  colored  plate, 

oi   t^'-   '■■• ■■-    '•    -   1 

TL 
eunveiiU-ur 


ccuratei 


i\ 


\ 

4 

■<       fl 

t      1 

.•an  be  made  to  ans^v 

he   shape   ;;^  ''     ^  " 
''e  shown  iv. 
c  needli 
■^'on  \vi;ii 
lion  of  ' 
is  used  tor  this 

Tlir        : 
thof.' 


.1  ,>.,.., 


m3TU  xiyaaD  an'i  lJ  aoq  yionAaaiO 


>,  silT 


LACERATIONS  OP  THE   CERVIX  UTERI. 


255 


each  side,  so  as  to  bring  the  tissues  more  within  the  grasp  of  the 
scissors. 

The  blades  of  the  scissors  are  then  closed,  and  a  strip  is  removed 
from  above  downward  on  each  flap.     The  other  side  is  treated  in 


Fig.   116. — Hawk-bill  scissors. 

the  same  way,  and  the  most  important  part  of  the  denudation  is  com- 
pleted. It  frequently  happens  that  a  portion  of  the  tissue  to  be  so 
removed  escapes  from  the  scissors  at  the  lower  portion  of  the  flaps 
on  one  or  both  sides ;  but  when  this  happens,  the  denudation  is 
easily  completed  with  the  ordinary  curved  scissors.  If  the  curved 
scissors  only  are  used,  much  difficulty  is  experienced  in  vivifying 
the  upper  angles  of  the  laceration,  but  with  the  hawk-bill  scissors 
this  portion  of  the  operation  can  be  accomplished  accurately  and 
with  facility.  The  hawk-bill  scissors,  while  saving  time  and  trouble, 
give  smoother  surfaces  for  coaptation  than  can  be  otherwise  ob- 
tained. A  faithful  trial  of  both  methods  by  myself,  and  observa- 
tions of  the  old  method  as  practiced  by  the  most  expert  surgeons 
convince  me  of  this  fact.  It  has  been  said  that  all  the  cicatricial 
tissue  can  not  be  removed  with  the  hawk- bill  scissors.  In  regard  to 
that,  I  can  say  that  I  have  always  succeeded  in  removing  all  that 
was  necessary  to  secure  good  union  and  satisfactory  ultimate  results. 
Fig.  117,  colored  plate,  shows  the  two  denuded  surfaces  on  each  side 
of  the  laceration  and  the  strip  of  the  mucous  membrane  between. 
The  needles  used  are  triangular  and  pointed.  Three  lengths  are 
convenient  to  have,  but  the  medium  one  can  be  made  to  answer  for 

all.     The   shape   and    length   of 
these  are  shown  in  Fig.  IIS. 

The  needle-forceps  described 
in  connection  with  the  operation 
for  restoration  of  the  pelvic  floor 
is  used  for  this  operation. 

The  sutures  are  introduced  in 
the  following  mannei  :  The  nee- 
dle is  placed  in  that  groove  of  the 
Fig.  118.— Triangular  needles.  needle  -  forceps   which  will   give 


256  DISEASES  OP  WOMEN. 

the  desired  angle,  and  is  held  immovable  there,  while  the  operator 
grasps  the  handle  and  closes  the  catch.  The  needle  is  then  passed 
into  the  tissue,  and  left  there  while  the  forceps  is  unclasped  and 
reversed.  Its  other  end  is  then  used  to  grasp  the  point  of  the 
needle  and  draw  it  through.  The  iirst  two  sutures  are  introduced 
at  the  lower  end  of  the  tiaps,  at  points  corresponding  to  the  sides 
of  the  OS  internum.  In  some  cases,  when  the  parts  do  not  come 
together  easily,  it  is  M'ell  to  introduce  first  a  suture  on  each  side  at 
the  upper  end  of  the  wound,  and  then  the  two  lower  ones.  While 
introducing  the  first  two  sutures  the  parts  are  held  by  the  tenaculum 
forceps,  which  were  used  during  denudation.  As  each  suture  is 
introduced,  the  ends  are  united  by  passing  one  around  the  other  in 
a  loop-knot.     This  keeps  the  sutures  from  being  tangled. 

The  tenaculum  forceps  is  then  removed,  and,  while  an  assistant 
steadies  the  ceiwix  by  holding  the  ends  of  the  first  sutures,  the  others 
are  introduced,  a  tenaculum  being  used  to  make  counter-pressure 
while  the  needle  is  passed. 

The  sutures  are  tied  as  follows :  One  or  two  turns  of  the  ends 
are  made  to  form  the  first  half  of  the  knot,  the  assistant  takes  hold 
of  one  end,  the  other  is  passed  through  the  loop  of  a  counter-pressure 
instrument,  and  then  seized  by  the  left  hand  of  the  operator.  Trac- 
tion is  then  made  on  both  ends  of  the  suture,  and,  at  the  same  time, 
the  loop  of  the  instrument  is  pushed  down  along  the  thread  to  make 
the  knot  slip  to  its  destination.  Repeating  this  manceuvre  completes 
the  knot.  The  instrument  used  is  about  the  size  and  shape  of  an 
ordinary  Sims's  tenaculum,  but,  in  place  of  having  a  hook-^^oint,  it 
terminates  in  a  ring  (Fig.  119). 


G.TIEMANN   hCO. 


Fig.  119. — Ring-tenaculum  or  counter-pressure  instrument. 

By  this  method  the  sutures  can  be  tied  about  as  easily  and  rap- 
idly in  the  cavity  of  the  vagina  as  upon  a  free  surface.  The  ends  of 
the  sutures  are  then  cut  off,  and  a  small  tampon  of  well-dressed  fiax, 
saturated  with  pine  tar  (marine  lint),  is  carefully  packed  in,  first 
around  the  cervix,  and  then  below  it.  This  tampon  makes  a  good 
antiseptic  dressing.  It  promptly  absorbs  serous  oozing,  and  pre- 
vents any  motion  of  the  uterus  which  might  strain  the  sutures.  At 
tlie  end  of  forty-eight  hours  it  sliould  be  removed,  and,  if  the  parts 
are  then  in  a  healthy  condition,  no  further  local  treatment  is  required. 
If  there  is  any  suppuration,  a  fresh  tampon  should  be  introduced, 
and  allowed  to  remain  for  forty-eight  hours  longer. 

From  my  experience  in  a  large  number  of  cases,  I  am  satisfied 


LACERATIONS  OP  THE  CERVIX  UTERI.  257 

that  the  use  of  the  tampon  is  a  reliable  after  treatment  in  this  opera- 
tion, and  is  preferable  to  the  daily  injection  of  carbolized  water, 
which  so  many  employ. 

The  patient  should  rest  in  bed,  with  the  privilege  of  turning 
upon  either  side.  The  bowels  and  bladder  should  be  evacuated  upon 
the  ])ed-pan. 

The  sutures  should  be  removed  upon  the  eighth  or  ninth  day. 
If  union  is  imperfect,  the  lower  ones  may  be  left  in  for  two  weeks. 

The  simplicity  of  the  after  treatment  is  its  chief  merit.  Keep- 
ing the  patient  perfectly  still  in  bed  is  a  great  punishment  to  one  in 
good  general  health,  and  tends  to  prevent  union ;  hence,  giving 
the  patient  the  j)rivilege  of  tossing  about  on  the  bed  is  a  great  com- 
fort. I  am  inclined  to  think  that  I  could  give  the  patient  liberty  to 
get  out  of  bed  to  evacuate  the  bowels  and  urinate,  if  the  tampon  was 
employed  continuously.  As  bearing  on  this  point  I  may  refer  to 
the  case  that  I  operated  upon  in  my  office,  and  sent  home  in  the 
street-cars.  She  made  a  perfect  recovery.  Another  case  shows  what 
can  be  done  with  impunity.  A  patient  of  Dr.  George  W.  Baker's, 
a,  very  strong,  active  lady,  was  operated  upon  for  a  bilateral  lacera- 
tion in  the  usual  way.  She  refused  to  stay  in  bed,  but  rested  on  the 
sofa,  and  visited  the  water-closet  when  necessary.  Her  menses  came 
on  prematurely  and  profusely.  A  large  coagulum  formed  in  the 
vagina  and  was  passed  while  straining  in  the  water-closet,  ^ot  the 
shghtest  hope  of  success  was  entertained,  bat  on  removing  the 
sutures  the  results  were  found  satisfactory  in  every  way.  These 
cases  convinced  me  that  the  absolute  quietude  usually  insisted  ujDon 
is  not  necessary,  and  hence  since  then  I  have  given  more  liberty  of 
action.  Much  discomfort  is  avoided  in  this  way,  and  the  patient 
gets  up  better  and  stronger. 

ILLUSTRATIVE    CASES. 

Typical  Case  of  Bilateral  Uncomplicated  Laceration  of  the  Cervix 
"Uteri. — The  patient  was  twenty-four  years  of  age,  and  had  her  lirst 
child  fourteen  months  before  she  was  first  examined.  Her  general 
health  was  fairly  good,  but  she  had  backache  and  profuse  leucor- 
rhoja.  Walking  or  standing  gave  her  pelvic  tenesmus,  and  she  was 
more  easily  fatigued  than  in  former  years.  She  began  to  menstruate 
ten  months  after  her  confinement,  and  gave  up  nursing  her  child 
when  it  was  a  year  old.  The  menses  were  normal,  but  more  free 
than  formerly,  and  lasted  a  day  longer.  She  was  sterile.  Physical 
examination  showed  that  the  uterus  was  a  little  larger  than  it  usually 
is  in  a  person  of  her  size.  The  cervical  mucous  membrane  was 
18 


258  DISEASES  OP  WOMEN. 

hyperaemic,  and  denuded  of  epithelium  in  certain  places.  There 
was  a  profuse  leucorrhcea. 

The  cervical  canal  was  cleared  of  the  leucorrhcEal  discharge,  and 
an  application  of  equal  parts  of  tincture  of  iodine  and  carbolic  acid 
was  made.  This  was  repeated  at  the  end  of  a  week  and  after  the 
succeeding  menstruation.  The  cervix  was  restored  in  the  way  al- 
ready described  without  using  an  anaesthetic. 

Figs.  120  and  121,  colored  plate,  show  the  cervix  with  the  sutures 
in  position.  A  marme-lint  tampon  was  used  and  kept  in  position 
for  forty-eight  hours.  No  after-treatment  was  needed.  The  sutures 
were  removed  on  the  tenth  day,  and  the  union  was  complete.  The 
patient  was  kept  in  bed  two  weeks  in  all,  and  during  that  time  was 
given  a  good,  generous  diet,  and  her  bowels  were  moved  daily.  She 
had  no  pain  during  her  rest  in  bed,  and,  although  weak  when  she 
first  tried  to  walk,  she  soon  regained  her  strength.  After  the  re- 
moval of  the  sutures  a  vaginal  douche  of  borax  and  water  was  used 
up  to  the  time  of  the  next  menstrual  period.  Three  months  after 
the  operation  she  was  free  from  all  her  former  symptoms.  The 
cervix  then  appeared  like  that  of  an  imparous  uterus. 

Bilateral  Laceration  complicated  with  Enlargement  of  the  Cervix 
from  Hyperplasia. — This  patient  had  her  only  child  when  she  was 
twenty-six  years  old.  Her  labor  was  tedious,  but  otherwise  normal. 
From  the  time  of  her  confinement  until  I  first  saw  her,  four  years 
afterward,  she  had  not  been  well.  She  suffered  from  backache,  pel- 
vic tenesmus,  and  profuse  leucorrhoea.  Her  general  health,  which 
was  formerly  very  good,  became  impaired.  The  appearance  of  the 
cervix  when  first  seen  is  shown  by  Fig.  110. 

It  was  impossible  to  bring  together  the  edges  of  the  os  exter- 
num, owing  to  the  enlargement  of  the  halves  of  the  cervix.  Con- 
stitutional treatment  was  employed,  and  the  hot-water  douche  and 
tincture  of  iodine  used  locally,  but  at  the  end  of  two  months  there 
was  only  a  slight  improvement  in  the  condition  of  the  cervix.  A  pre- 
liminary operation  was  then  performed  as  follows  :  A  crescentic- 
shaped  piece  of  tissue  was  removed  from  the  inner  side  of  each 
half  of  the  cervix  sufiiciently  deep  to  permit  the  halves  to  be 
brought  together  with  very  little  traction.  Fig.  122  shows  the  por- 
tions removed  ;  the  dark  lines  indicate  the  lines  of  incision.  Two 
sutures,  one  on  each  side  of  the  os  externum,  were  introduced  to 
hold  the  parts  together  while  healing  was  going  on.     Figs.  123  and 

124  show  the  parts  brought  together  with  the  sutures,  and  Figs. 

125  and  126  show  a  different  method  of  doing  the  same  operation. 
Before  tying  the  sutures  a  piece  of  muslin  saturated  with  wax  was 


LACERATIONS  OF   THE   CERVIX  UTERI. 


259 


placed  between  the  halves  of  the  cervix,  and  left  there  for  four 
days  to  keep  the  coaptated  parts  from  meeting.     The  sutures  were 


Fig.   122. 


Fig.   123. 


Fig.  124. 


Fig.  125  Fig.  126. 

Figs.  125  and  126. — Another  method  of  closing 
the  gap. 


Fig.  122. — Removal  of  crescentic  shaped  piece  (seen  in  section)  when  the  everted  lips  are 
thickened.    Figs.  123  and  124. — Method  of  bringing  the  sides  of  the  sections  together. 

removed  at  the  end  of  two  weeks,  when  it  was  found  that  the  parts 

where  the  exsections  were  made  had  nearly  healed  over.     Three 

weeks  afterward  the  cervix 

was   restored    in    the   usual 

way,    and   good    union  was 

obtained,    and    the    patient 

subsequently  recovered. 

In  cases  like  this  I  have 
sometimes  removed  the  re- 
dundant tissue  of  the  cer- 
vix at  the  time  of  perform- 
ing the  final  operation  for 
the  restoration  of  the  cervix.  Wlien  this  is  done,  it  is  necessary  to 
keep  a  plug  in  the  cervical  canal  during  the  healing  process  in  order 
to  prevent  the  vivified  portions  from  uniting. 

I  much  prefer  to  do  the  preliminary  operation,  believing  that  I 
can  get  better  results  by  so  doing. 

Laceration  of.  the  Posterior  "Wall  of  tlie  Cervix  TJteri,  complicated 
with  Ealargement  of  the  Cervix  and  Cystic  Degeneration  of  the  Mucous 
Membrane. — The  patient  was  first  seen  when  thu'ty-foiu'  years  of  age, 
and  had  been  married  thirteen  years.  The  injuiy  of  the  cervix  oc- 
curred twelve  years  before,  when  she  had  her  only  child.  She  got 
up  from  her  confinement  with  leucorrhoea,  backache,  and  pelvic 
tenesmus,  and  continued  to  suffer  from  these  for  about  one  year, 
when,  becoming  tired  of  being  told  that  her  pelvic  symptoms  would 
disappear  when  she  gained  her  strength,  she  consulted  another  phy- 
sician. Local  treatment  was  then  employed  with  benefit,  but  it 
proved  to  be  temporary.  The  leucorrhoea  and  other  svmptoms  re- 
turned in  an  aggravated  form.  She  continued  in  this  way.  getting  a 
little  temporary  relief  from  treatment  and  again  going  uncared  for- 


260  DISEASES  OF   WOMEN. 

up  to  the  time  that  she  came  under  my  care.  For  three  months 
she  was  treated  for  cystic  degeneration,  catarrh,  and  hypertrophy  of 
the  cervix.  The  latter  appeared  to  be  due  to  imperfect  involution 
and  hyperplasia  combined.  The  laceration  extended  up  to  the  vagi- 
nal junction,  and  there  were  erosion  and  eversion,  but  not  to  any 
great  extent.  In  restoring  the  cervix,  its  sides  were  seized  with  the 
tenaculum  forceps,  and  the  upper  angle  of  the  laceration  vivilied 
with  the  hawk-bill  scissors.  The  denudation  was  carried  down- 
ward to  the  OS  externum  with  the  curved  scissors.  The  introduc- 
tion of  the  sutures  and  the  after-treatment  were  conducted  as 
usual.  The  union  was  satisfactory  in  every  way.  There  was  no 
return  of  the  former  symptoms,  and  she  was  classed  among  the  suc- 
cessful cases,  although  she  remained  sterile  without  any  apparent 
cause  for  it. 

Multiple  Laceration  of  the  Cervix. — A  large,  muscular  lady  had  her 
first  child  when  she  was  twenty-six  years  old.  Her  labor  was  tedious, 
the  membranes  rupturing  before  the  cervix  was  fully  dilated.  Man- 
ual dilatation  was  resorted  to,  and  the  forceps  used  to  deliver  before 
the  bead  had  fully  descended  into  the  pelvis.  This  much  of  the 
history  was  obtained  from  the  physician  who  attended  her  in  confine- 
ment. Four  years  subsequently  I  first  examined  her  and  found  a 
multiple  laceration  of  the  cervix.  The  irregular  nodulated  state  of 
the  cervix  and  its  density  to  the  touch  suggested  the  thought  that 
there  might  be  malignant  disease  present.  This  suspicion  was  still 
further  aroused  by  a  speculum  examination,  which  revealed  a  profuse 
leucoiThoea  and  a  rough,  vascular,  papillomatous  state  of  the  mucous 
membrane.  The  fact  that  the  parts  improved  promptly  on  treat- 
ment settled  the  diagnosis.  The  cervix  was  divided  into  three  un- 
equal parts  (Fig.  112).  For  two  months  she  was  treated  for  the  in- 
flammation of  the  cervix,  and  at  the  end  of  that  time  the  laceration 
of  the  posterior  wall  was  operated  upon  in  the  usual  way.  It  was 
not  necessary  to  anaesthetize  the  patient,  as  the  operation  required 
only  a  short  time  and  was  not  very  painful.  She  was  kept  in  bed 
for  a  week,  and  good  union  was  obtained.  This  left  the  patient 
with  a  simple  bilateral  laceration,  which  was  successfully  operated 
upon  five  weeks  afterward. 

Multiple  Laceration  incomplete,  complicated  with  Endometritis  Poly- 
posa. — The  patient  was  thirty -seven  years  old,  married  seventeen 
years,  and  had  borne  three  children,  the  youngest  of  whom  was  two 
years  of  age.  It  was  impossible  to  ascertain  when  the  cervix  was 
injured.  The  history  showed  that  her  health  l>egan  to  fail  after  the 
birth  of  her  second  child,  and  that  she  broke  down  completely  after 


LACERATIONS  OF   THE   CERVIX  UTERI.  261 

her  third  one  was  born.  When  she  came  under  my  observation  she 
had  menorrhagia,  a  poor  appetite,  and  constipation.  She  was  ema- 
ciated, very  ansemic,  irritable,  sleepless,  and  suffered  much  from 
headaches — in  short,  was  perfectly  useless,  and  a  great  sufferer.  She 
had  free  leucorrhoea,  backache,  and  ovarian  pain,  which  was  at  times 
quite  annoying. 

The  physical  signs  indicated  that  there  was  a  polypoid  state  of 
the  endometrium.  There  were  four  lacerations  of  the  cervix.  Two 
lateral,  the  largest,  and  one  in  the  anterior  wall  and  another  in  the 
posterior  wall  These  latter  might  be  called  fissures.  They  did 
not  extend  through  the  whole  of  the  middle  coat  of  tlie  cervix. 
The  lateral  lacerations  were  complete,  involving  the  entire  wall  of 
the  cervix  for  about  a  quarter  of  an  inch  below  and  were  incom- 
plete above.  The  fungosities  of  the  endometrium  were  removed 
with  the  curette.  This  relieved  the  menorrhagia  and  improved  the 
general  health  of  the  patient  to  some  extent.  The  restoration  of 
the  cervix  was  effected  by  operating  upon  the  lateral  lacerations  in 
the  prescribed  way,  i.  e.,  first  making  complete  lacerations  of  them, 
and  then  vivifying  the  parts  and  closing  them  with  sutures.  The 
antero-posterior  lacerations  or  fissures  were  treated  by  vivifying 
their  sides  as  well  as  could  be  done  before  closing  the  lateral 
ones.  When  the  sutures  were  tightened  in  the  lateral  lacerations 
it  was  found  that  the  traction  appeared  to  hold  the  antero-posterior 
lacerations  together.  The  result  proved  that  such  was  the  case. 
There  was  good  union,  and  the  patient  gained  in  strength  rapidly 
and  was  quite  well  at  the  end  of  three  months. 

Typical  Case  of  Bilateral  Incomplete  Laceration  of  the  Cervix 
Uteri. — The  patient,  a  lady  of  excellent  physique,  married  at  thirty- 
one  years  of  age,  and  had  her  first  child  three  years  later.  Her  labor 
was  tedious  in  the  first  stage,  but  her  recovery  was  without  any 
marked  interruption.  When  her  child  was  twenty  months  old  she 
became  pregnant  again,  and  miscarried  at  the  third  month.  Six 
months  after  her  miscarriage  she  was  first  examined.  She  then 
suffered  from  menorrhagia,  pelvic  tenesmus,  and  profuse  leucor- 
rhoea, which  caused  some  general  depression — but  not  to  any  great 
extent.  The  utenis  was  retroverted,  and  the  cervical  canal  admitted 
the  index-finger  nearly  to  the  internal  os.  The  uterus  was  a  little 
larger  than  normal,  and  its  mucous  membrane  congested  and  irrega- 
lar  to  the  touch  of  the  sound. 

The  uterus  was  restored  to  its  position  and  retained  there  with 
a  pessary.  The  canal  of  the  cervix  was  touched  with  tincture  of 
iodine.     This  gave  her  relief  from  tenesmus,  but  did  not  control 


\ 

262  DISEASES  OF  WOMEN. 

tlie  menorrliagia  nor  the  leiicorrh(ea.  Subsequently  the  cavity  of 
the  uterus  was  curetted,  and  carbolic  acid  and  iodine  were  apj^lied 
to  the  canal  of  tlie  cervix.  From  this  time  on  the  menses  were  nor- 
mal, but  the  leucorrhoea  returned  again  and  again.  Treatment 
would  arrest  it  for  a  time,  but  it  returned,  and  she  proved  to  be  ster- 
ile, Eestoration  of  the  cervix  was  proposed  in  the  hoj)e  that  the 
operation  would  give  her  permanent  relief. 

The  operation  was  performed  as  follows :  Taking  hold  of  the 
anterior  and  postei'ior  walls  of  the  cervix  with  the  tenaculum  for- 
ceps, a  straight  scissors  was  passed  into  the  cervix  half  its  entire 
length,  and  the  mucous  membrane  of  the  vagina  (the  pcjrtion  of  the 
cervical  wall  which  escaped  laceration)  was  divided.  The  other  side 
was  treated  in  the  same  way.  The  halves  of  the  cervix  were  drawn 
apart,  so  that  the  extent  of  the  internal  laceration  could  be  clearly 
seen,  and  then  the  angle  on  each  side  was  vivified  with  the  hawk- 
bill  scissors.  After  this  there  still  remained  a  little  redundant  vagi- 
nal mucous  membrane  at  the  lower  portion  of  the  cervix,  and  Ije- 
tween  the  vaginal  and  cervical  mucous  membrane  the  site  of  the 
laceration,  the  muscular  walls  remained  modified.  The  redundant 
vaginal  membrane  was  removed  and  the  middle  walls  of  the  cer^ax 
were  vivified  with  the  curved  scissors.  This  modification  of  the 
method  of  vivifying  the  parts  to  be  united  became  necessary  because 
of  the  lacerations  being  incomj^lete. 

In  some  cases  of  incomplete  laceration  when  the  cervix  is  large, 
it  is  best  to  divide  the  vaginal  mucous  membrane  first.  By  using 
the  hawk-bill  scissors  a  V-shaped  piece  can  be  taken  out  on  each  side 
which  completes  the  vivifying  with  a  single  clip  of  the  scissors  on 
each  side. 

The  sutures  were  introduced  and  the  operation  com])leted  in 
the  usual  way.  The  case  progressed  favorably,  union  was  complete, 
and  there  has  been  no  return  of  the  leucorrhoea  nor  any  of  her  for- 
mer symptoms. 

Incomplete  Laceration  with  Hypertrophy  of  the  Anterior  Half  of  the 
Cervix. — The  ]iatient  had  suffered  from  a  profuse  leucorrhoea  since 
the  birth  of  her  child  five  years  before,  ^he  had  been  treated  oc- 
casionally, and  derived  only  temporary  relief,  the  symptoms  return- 
ing again  when  treatment  was  suspended.  The  enlargement  of  the 
anterior  half  of  the  cervix  was  confined  mostly  to  the  mucous  mem- 
brane. This  gave  a  crescentic  appearance  to  the  os  exteriuim  (Fig. 
115).  The  treatment  consisted  of  exsection  of  the  hypertrophied 
portion  of  the  mucous  meml)rane  in  the  antei'ior  wall,  and  when 
the  ])arts  had  healed  the  laceration  was  operated  on  in  the  same 


LACERATIONS  OF   THE  CERVIX  UTERI.  203 

manner  as  in  the  case  of  incomplete  laceration  preceding  this 
■one. 

The  exsection  was  made  by  seizing  the  part  to  be  removed  with 
A  tissue  forceps,  and  with  a  sHghtly-curved  scissors,  clipping  oft:  the 
whole  of  the  mucous  membrane  on  that  side  up  as  high  as  the  hy- 
pertrophy extended.  There  was  some  bleeding,  but  that  was  very 
■easily  controlled  by  packing  the  cervical  canal  with  cotton,  and 
using  a  vaginal  tampon  to  keep  it  there. 

The  Results  of  the  Surgical  Treatment  of  Lacerations  of  the  Cervix 
Uteri. — There  are  some  points  that  remain  to  be  settled  by  reliable 
■observations  regarding  the  results  of  the  surgical  treatment  of  these 
injurieSo  More  statistics  by  reliable  observers  are  needed  to  deter- 
mine definitely  all  the  benefits  which  may  be  reasonably  expected 
from  this  form  of  treatment. 

It  may  be  fairly  claimed  that  successful  restoration  of  the  cervix 
-will  relieve  the  inflammatory  troubles  of  the  cervix,  including  the 
-suffering  from  scar  tissue  in  the  great  majority  of  cases. 

Sterility  due  to  the  injury  of  the  cervix  and  the  consequent  le- 
gions is  cured  in  many  cases. 

Labor  is  not,  as  a  rule,  retarded  by  the  condition  of  the  cervix 
^fter  the  operation.  Kor  does  laceration  necessarily  occur  again. 
I  have  been  able  to  compare  the  dilatability  of  the  cervix  after 
"tracheiorraphy  with  that  of  lacerated  cervix  with  scar  tissue,  and  I 
have  found  that  the  results  are  greatly  in  favor  of  those  patients  in 
-whom  the  cervix  has  been  restored. 


CHAPTER  XV. 

CICATRICES    OF   THE    CERVIX   UTERI   AND   VAGINA. 

Cicatrices,  the  results  or  products  of  diseased  action  aud  inju- 
ries, are  of  pathological  importance  according  to  their  size  and  loca- 
tion.  They  derange  the  conditions  of  health  and  comfort  by  the 
tender  and  painful  character  of  scar  tissue,  and  by  its  inelasticity, 
which  interferes  with  the  free  motion  of  the  pelvic  organs.  The 
slow,  persistent  contraction  of  this  abnormal  tissue,  by  which  the 
adjacent  normal  parts  are  united,  causes  pain  by  making  pressure  on 
the  terminal  nerve-libers.  Tenderness,  also  a  characteristic  of  scar 
tissue,  is  developed  in  the  same  way,  or  perhaps  from  the  excessive 
irritability  or  imperfect  protection  of  the  nerves  found  in  cicatrices. 
This  tenderness  is  most  marked  in  scars  at  or  near  the  introitus 
vaginae,  and  varies  according  to  the  age  of  the  new  tissue.  When 
an  uninterrupted  cicatrix  surrounds  the  cervical  canal,  the  os  ex- 
ternum, or  the  vagina  at  any  point,  stenosis  is  produced,  and  all  the 
derangements  consequent  thereon,  according  to  the  partial  or  com- 
plete development  of  the  stricture. 

Causation. — The  causes  which  lead  to  the  formation  of  cicatrices 
are  familiar  to  all,  and  require  only  to  be  named  in  order  to  I'ccall 
them  for  present  consideration  :  Injuries  during  parturition  suffi- 
cient to  cause  sloughing  or  loss  of  tissue  ;  lacerations  which  heal  over 
without  uniting  the  divided  parts,  or  which  are  united  by  interven- 
ing new  tissue ;  amputation  of  the  vaginal  portion  of  the  cervix ; 
exsection  of  a  portion  of  the  vagina,  es])ecially  where  healing  takes 
place  by  granulation  ;  destruction  of  the  mucous  membrane  and  sub- 
jacent structures  by  the  free  use  of  caustics,  and  extensive  ulceration 
either  simple  or  sjiecitic.  These  are  the  chief  affections  which  give 
rise  to  the  conditions  now  under  consideration. 

Syraptoinatology. — The  principal  symptom  developed  by  cica- 
trices is  pain,  which  is  often  intermittent  or  remittent,  and  is  usually 
increased  by  exercise.    When  the  scar  involves  the  circumference  of 

204 


CICATRICES   OF   THE   CERVIX   UTERI   AND   VAGINA.  265 

the  cervix,  and  the  caHber  of  the  canal  is  reduced  below  the  normal 
size,  dysnienorrhoja  occurs  in  some  cases.  When  the  vagina  is  ex- 
tensively involved,  the  functions  of  the  bladder  and  rectum  are  occa- 
sionally deranged  so  as  to  give  rise  to  frequent  and  difficult  urination 
and  painful  defecation.  This  is  due,  doubtless,  to  the  tenderness  of 
the  scar  tissue  and  diminished  mobility  of  the  parts.  For  the  same 
reason,  coition  is  painful,  and  in  some  marked  cases  impossible.  It 
will  be  observed  that  the  same  derangement  of  the  sexual  function 
occurs  in  vaginitis,  vaginismus,  and  in  that  rare  neurotic  affection 
in  which  there  is  extreme  hypersesthesia  without  any  apparent 
change  of  structure  or  circulation  to  account  for  it.  In  short,  any 
or  all  of  the  symptoms  caused  by  cicatrices  may  arise  from  other 
pathological  conditions,  such  as  are  found,  for  example,  in  conva- 
lescence from  pelvic  peritonitis  or  cellulitis.  On  that  account  the 
diagnosis  must  be  based  chiefly  on  the  physical  signs. 

Physical  Signs. — These  I  may  briefly  mention.  They  are  the 
presence  of  abnormal  tissue,  which  is  usually  tender,  always  indu- 
rated, less  elastic  than  healthy  parts,  and  sometimes  lighter  in  color, 
and  having  a  smooth  surface.  Cicatrices  of  the  vagina  are  easily 
detected ;  those  of  the  cervix  are  liable  to  be  confounded  with 
sclerosis  and  incipient  malignant  disease.  The  points  of  distinc- 
tion are  the  increase  of  tissue  and  abnormal  vascularity  found  in  the 
latter. 

Treatment. — Knowing  the  evils  which  cicatrices  give  rise  to,  the 
first  duty  of  the  practitioner  is  to  guard  against  their  formation. 
This  can  be  accomplished  to  a  great  extent,  I  am  sure,  by  observing 
certain  lines  of  practice.  Lacerations  of  the  pelvic  floor,  occurring 
during  natural  or  artificial  delivery,  should  be  immediately  brought 
together  by  sutures,  when  it  is  possible  to  do  so,  in  place  of  leaving 
them  to  heal  as  best  they  may,  which  is  the  usual  practice.  In  many 
such  cases  the  patient  is  anaesthetized  when  the  injury  is  sustained, 
and,  if  the  obstetrician  has  the  requisite  instruments  at  hand — as  he 
ought  to  have — the  operation  of  closing  such  wounds  with  sutures  is 
practicable ;  if  such  wounds  can  be  made  to  heal  without  the  inter- 
vention of  much  new  tissue,  the  cicatrices  are  very  unimportant  com- 
pared with  the  large  scars  which  are  sometimes  formed  where  healing 
takes  place  by  granulation. 

In  making  these  statements,  I  am  aware  that  the  ground  taken 
may  be  questioned.  In  opposition  to  this  practice,  it  may  be  said 
that  such  wounds  often  heal  promptly  without  the  aid  of  sutures, 
and  even  when  sutures  are  employed  there  is  no  certainty  that  good 
union  will  take  place.     On  the  other  hand,  it  can  be  fairly  claimed 


266  DISEASES  OF  WOMEN. 

that,  if  the  edges  of  a  lacerated  wound  are  held  together,  the  chances 
of  their  uniting  are  better  than  if  left  alone.  Ev^en  should  healing 
take  place  by  granulation,  the  sutures,  preventing  the  wide  separa- 
tion of  the  parts,  will  tend  to  lessen  the  size  of  the  cicatrix.  When 
there  is  so  much  to  be  gained  by  good  union,  and  so  much  suffering 
entailed  by  bad,  the  use  of  sutures  in  such  cases  is  surely  good 
surgery. 

The  formation  of  troublesome  cicatrices  following  the  use  of 
caustics  may  be  prevented  by  carefully  circumscribing  the  space  to 
which  they  are  applied,  and  by  avoiding  their  use  to  an  extent  suf- 
ficient to  cause  destruction  of  the  deeper  structures  of  the  mucous 
membrane.  When  it  is  necessary  to  apply  a  caustic — say  nitric  acid 
— to  the  OS  externum  or  cervical  canal,  a  portion  of  the  membrane 
should  be  left  untouched  if  possible,  so  that  the  eschar,  if  one  is 
formed,  will  not  completely  circumscribe  the  canal.  By  attention 
to  these  points  cicati'ices  may  be  prevented,  or,  if  they  follow,  they 
will  be  less  troublesome  in  character. 

In  the  treatment  of  cicatrices  the  chief  indications  are  to  relieve 
the  pain  and  tenderness  of  the  parts,  prevent  contractions,  and, 
where  deformities  exist,  to  correct  them.  These  requirements  cr.n 
be  most  promptly  and  perfectly  fulfilled  by  removing  the  whole  of 
the  cicatrix  and  bringing  together  the  normal  tissues,  and  obtain- 
ing as  near  immediate  union  as  possible.  But  this  radical  treat- 
ment is  only  called  for  in  rare  cases,  and  is  not  always  practicable, 
owing  to  the  size,  depth,  and  unfavorable  location  of  the  cica- 
trix. Exsection  should  not  be  undertaken  in  any  case  unless  the 
scar  is  movable  on  the  subjacent  tissue.  It  is  necessary  to  wait 
until  this  molulity  is  established,  which  usually  occurs  sooner  or 
later.  When  the  scar  can  not  be  removed  altogether,  contrac- 
tion should  be  guarded  against  by  preventing  it  from  shortening. 
In  oblong  cicatrices,  contraction  in  width  rarely  gives  trouble, 
while  shortening  causes  deformity.  This  can  often  be  prevented 
by  dividing  the  scar  at  one  or  more  points,  and  then  putting  the 
parts  on  the  stretch  by  the  tampon  or  pessary.  The  divided  edges 
thus  held  apart  are  united  by  intervening  new  tissue,  and  the  scar 
is  lengthened,  while  the  process  of  narrowing  still  continues.  Some- 
times the  contractility  of  the  normal  tissues  is  sufficient  to  draw  the 
divided  edges  of  the  scar  apart,  so  that  incising  the  scar  is  all  that 
is  necessary. 

When  a  cicatrix  surrounds  the  os  externum  it  should  l)e  divided 
on  two  sides,  tbe  lateral  being  ]>ref(M'able  in  most  cases;  a  tent  of 
sea-tangle  should  then  be  introduced  and  worn  during  the  process 


CICATRICES  OF   THE   CERVIX  UTERI   AXD  VAGINA.         267 

of  liealing.  The  tent  slioulcl  be  short,  so  as  not  to  enter  the  internal 
OS,  and  it  can  be  held  in  position  by  a  pessary  by  stitching  it  to  the 
walls  of  the  cervix.  The  frequent  use  of  the  sound  or  dilator  will 
answer  the  same  purpose. 

In  the  management  of  cicatrices  of  tlie  vagina,  very  satisfactory 
results  are  obtained  by  the  treatment  proposed.  After  dividing  the 
cicatrix,  the  parts  are  put  upon  the  stretch  by  the  glass  dilator  em- 
ployed by  Sims  and  others  in  the  treatment  of  atresia  vaginse.  I 
have  also  used  for  the  same  purpose  elm-bark,  made  into  a  roll  of 
the  proper  length  and  thickness  and  beaten  until  it  is  soft.  It  is 
then  dipped  in  carbolized  water  and  introduced  like  a  pessary.  This 
has  the  advantage  of  being  agreeable  to  the  tissues,  and  by  expand- 
ing very  slowly  it  causes  distention,  which  is  easily  borne.  By  en- 
larging from  day  to  day  the  size  used,  the  vagina  can  be  distended 
slowly  and  without  pain.  I  am  satisfied  that  this  method  of  treatment 
has  another  advantage,  which  is,  that  by  slow,  continuous  dilatation 
the  normal  portions  of  the  vagina  can  be  developed  so  as  to  compen- 
sate for  the  contraction  of  the  cicatrix  to  a  very  considerable  extent. 

When  there  is  no  marked  deformity,  and  pain  and  tenderness 
are  the  only  symptoms,  great  relief  will  often  follow  an  incision  of 
the  cicatrix  at  a  number  of  points.  I  have  also  been  led  to  believe 
that  softening  of  the  scar  and  relief  from  pain  were  obtained  by  the 
frequent  application  of  equal  parts  of  tincture  of  opium,  aconite, 
and  iodine. 

A  word  might  be  said  about  complications,  such  as  vaginitis, 
cervical  endometritis,  etc.  They  are  to  be  treated  in  the  usual  way, 
of  course.  I  need  only  add  that,  so  far  as  my  observations  have  ex- 
tended, it  has  been  found  that  by  relieving  trouble  caused  by  cica- 
trices, recovery  from  accompanying  affections  is  facilitated.  This  is 
as  might  be  expected. 

ILLUSTRATIVE    CASES. 

Scar  Tissue  producing  Stenosis  of  the  Vagina.  Primary  Cause : 
Acute  Inflammation  during  the  Course  of  the  Fever. — A  lady,  thirty 
years  of  age,  large,  well  formed,  and  in  general  good  health,  men- 
struated first  at  fifteen  vears  of  ao'e,  and  has  continued  to  do  so 
regularly  and  normally  ever  since.  She  has  been  married  twelve 
years,  and  during  that  time  coition  has  been  impossible.  Before 
marriage  she  had  no  symptoms  of  uterine  disease,  but  soon  after  she 
developed  uterine  and  vaginal  leucorrhoea,  which  have  continued  in- 
termittently ever  since.  She  has  also  suffered  occasionally  from 
backache  and  irregular  pains  in  the  pelvis.     Examination   by  the 


268  DISEASES  OP  WOMEN. 

touch  revealed  contraction  of  the  whole  vagina,  so  that  the  index- 
finger  could  w^ith  difficulty  be  introduced,  and  at  the  upper  portion 
there  was  a  stricture  through  which  the  finger  could  not  be  passed. 
In  a  pocket  beyond  the  stricture  the  cervix  uteri  was  subsequently 
found.  The  stricture  was  due  to  scar  tissue,  which  formed  a  circular 
band  about  a  quarter  of  an  inch  wide.  P^rom  this  ring,  extending 
downward,  there  was  another  cicatrix  which  terminated  at  the  re- 
mains of  the  hymen.  There  was  subacute  vaginitis,  and  the  papillae 
of  the  mucous  membrane  were  enlarged  and  exceedingly  tender. 
The  examination  caused  intolerable  pain.  At  another  time  an  anaes- 
thetic was  given  and  the  stricture  divided.  The  uterus  was  then 
found  to  be  normal  in  size  and  shape,  but  there  was  a  little  erosion 
about  the  os  externum,  and  congestion  of  the  cervical  mucous  mem- 
brane and  hypersecretion. 

Nothing  in  the  history  of  the  case,  nor  in  the  local  lesions,  gave 
any  clew  to  the  cause  of  the  trouble,  but  on  re-examination  it  was 
found  that  when  the  patient  was  a  child  she  had  what  was  called 
typho-malarial  fever  followed  by  pelvic  inflammation  and  the  forma- 
tion of  abscesses. 

From  this  much  of  the  history  obtained  from  the  patient's 
mother,  I  presumed  that  the  cicatrices  of  the  vagina  were  the  prod- 
ucts of  the  disease  of  her  childhood. 

The  treatment  employed  in  this  case  was  such  as  has  been  de- 
scribed, and  marked  improvement  has  followed.  At  the  end  of  four 
months  after  beginning  the  treatment  the  vagina  admitted  Cusco's 
speculum  ;  the  tenderness  was  reduced,  but  not  wholly  relieved. 
The  patient  went  to  the  country  for  the  summer,  to  return  in 
October  for  further  treatment,  and  finally  recovered. 

Scar  in  the  Vaginal  Wall  resulting  from  an  Injury  sustained 
during  Labor. — I  was  called  to  see  a  lady  two  months  after  her  con- 
finement with  her  first  child.  I  learned  that  she  had  had  a  tedious 
labor  and  was  delivered  by  forceps.  She  made  a  good  recovery,  ex- 
cept that  when  she  undertook  to  stand  or  walk  she  suffered  from 
sharp  pains  in  the  vagina  and  a  feeling  of  dragging  and  weight, 
especially  on  the  left  side. 

On  examination  I  found  a  recent  cicatrix  on  the  left  side  extend- 
ing from  the  lower  portion  of  the  labium  majus  up  the  vagina  for 
about  three  inches.  The  scar,  which  was  about  half  an  inch  in 
width,  was  quite  tender  to  the  touch,  and  in  the  center  of  it,  here 
and  there,  a  few  granulations  remained  and  bled  on  being  roughly 
touched.  The  patient,  although  very  healthy  and  strong,  had  not 
been  able  to  go  up  or  down  stairs  or  leave  the  house  for  two  months 


CICATRICES  OF   THE  CERVIX  UTERI  AND   VAGINA.         269 

after  her  confinement,  the  time  when  I  saw  her.     No  otlier  uterine 
or  pelvic  disease  could  be  found. 

This  case  shows  the  trouble  which  wounds  of  the  vagina,  sus- 
tained during  confinement,  will  cause,  and  it  is  reasonable  to  suppose 
that  if  the  parts  had  been  united  by  sutures  at  the  time  of  injur}^  a 
more  prompt  recovery  would  have  followed. 

Scar  Tissue  between  the  Posterior  Wall  of  the  Cervix  Uteri  and 
Vagina,  caused  by  Former  Treatment. — This  lady  was  fifty  years  old 
and  had  passed  the  menopause  several  years.  Her  health  had  been 
very  good  during  most  of  her  life.  She  had  some  uterine  inflamma- 
tion and  leucorrhoea  after  the  birth  of  her  last  child,  and  was  treated 
with  caustic  applications  which  relieved  the  leucorrhcea.  After  this 
she  began  to  have  pelvic  pain  of  a  neuralgic  character,  which  in- 
creased gradually.  This  pain  was  greatly  aggravated  by  exercise. 
The  effect  of  the  local  suffering  and  inability  to  take  active  exercise 
upon  her  nervous  system  was  very  marked. 

A  vaginal  examination  by  the  touch  detected  a  thin  band  of  scar 
tissue  extending  from  the  posterior  wall  of  the  cervix  to  the  vaginal 
wall.  The  scar  was  quite  tender,  and  when  touched  with  the  probe 
or  finger  gave  rise  to  the  neuralgic  pain  from  which  she  generally  suf- 
fered. The  patient  was  placed  on  the  side,  and  a  Sims's  speculum 
introduced.  The  cervix  was  caught  with  a  tenaculum  and  drawn 
forward.  This  put  the  scar  tissue  on  the  stretch  and  made  it  promi- 
nent. The  whole  scar  tissue  was  removed  with  one  sweep  of  the 
curved  scissors,  and  the  edges  of  the  mucous  membrane  of  the 
vagina  were  united  with  a  few  catgut  sutures.  The  parts  healed 
without  delay,  and  all  the  local  pain  and  general  disturbances 
promptly  subsided.  The  relief  was  so  prompt,  complete,  and  per- 
manent, that  there  can  be  no  doubt  about  the  scar  tissue  being  the 
whole  cause  of  the  patient's  suffering. 

This  case  is  a  fair  sample  of  a  class,  now  fortunately  diminish- 
ing in  number,  in  whom  scars  are  produced  by  the  use  of  caustics. 
The  general  practitioner  using  a  Ferguson  speculum  and  a  swab  in 
treating  diseases  of  the  cervix  uteri,  usually  does  very  little  to  cure 
the  disease,  but  much  to  destroy  the  tissue  of  the  cervix  and  vagina. 
The  swab,  charged  with  a  strong  caustic  solution  and  pushed  up  into 
the  canal,  is  compressed  so  that  the  caustic  runs  down  on  the  poste- 
rior wall  of  the  cervix  and  vagina.  While  the  diseased  tissues  get 
very  little  of  the  application,  the  normal  tissues  at  that  point  are 
destroyed.  This  is  often  repeated,  and  results  in  forming  scar  tissue 
such  as  that  presented  in  this  case.  Such  results  of  treatment  were 
often  seen  years  ago,  and  at  the  present  day  they  are  far  too  common. 


270  DISEASES   OF   WOMEN. 

A  Band  of  Scar  Tissue  just  within  the  Introitus  Vaginae,  and 
extending  across  from  Side  to  Side  of  the  Vagina,  due  to  Forceps  De- 
livery.— ^Tlie  patient  was  undersized,  but  a  strong,  Liealtby  lady. 
She  was  confined  with  her  first  child  five  months  before  I  saw  her. 
Her  physician  told  me  that  the  child  was  large  in  proportion  to  the 
mother,  and  that  he  was  obliged  to  deliver  with  forceps  while  the 
head  was  high  in  the  pelvis.  In  the  delivery  much  damage  was 
done  to  the  cervix  and  vagina,  but  the  pelvic  floor  was  not  torn. 
She  recovered  slowly  from  her  labor,  and  continued  to  have  a  dis- 
charge, and  pain  mostly  of  a  neuralgic  character. 

I  found  a  semicircular  band  of  scar  tissue  running  from  the 
ramus  of  the  pubes,  high  up  and  around  the  vagina  to  the  opposite 
side.  The  scar  was  unyielding,  so  that  the  finger  could  only  be 
introduced  with  difliculty  into  the  vagina.  It  extended  deep  down 
below  the  mucous  membrane  of  the  vagina,  and  at  the  upper  ends 
was  fixed  to  the  pubic  bones.  It  appeared  to  me  that  in  the  original 
injury  the  whole  of  the  vaginal  wall,  together  with  the  bulbo-caver- 
nosus  muscles  and  the  anterior  fibers  of  the  levator-ani  muscle,  had 
been  torn  away  from  its  attachments  to  the  floor  of  the  pelvis. 

I  have  never  before  nor  since  seen  an  injury  exactly  like  this, 
and  hence  I  do  not  know  positively  how  it  was  produced,  but  pre- 
sume it  occurred  as  I  have  stated.  About  half  an  inch  from  the 
median  line  of  the  posterior  wall  of  the  vagina  the  scar  tissue  was 
divided  on  each  side.  Traction  backward  was  then  made  with  a 
narrow-bladed  Sims's  speculum,  which  distended  the  vulva  and  at 
the  same  time  brought  the  ends  of  the  incisions,  which  were  made 
parallel  to  the  axis  of  the  vagina,  together.  The  sides  of  the  incis- 
ions were  held  together  with  sutures.  The  immediate  effect  of  this 
operation  was  to  relieve,  in  a  marked  degree,  the  pains  from  which 
the  patient  had  suifered.  It  also  restoi'cd  the  dilatability  of  the 
vulva,  so  that  the  jiatient  could  resume  her  sexual  duties  when  the 
incisions  had  healed. 


CHAPTER   XVI. 


INVEESION    OF    THE   IJTEEUS, 


Inversion  may  be  defined  as  a  turning  inside  out  of  the  uterus, 
in  which  its  walls  descend  into  its  cavity.  The  external  surface  be- 
comes the  internal,  and  the  fundus  uteri,  which  should  be  highest 
in  the  pelvis,  becomes  lowest.  There  are  several  de- 
grees of  inversion,  varying  from  a  mere  depression 
of  a  portion  of  the  uterus,  to  a  complete  inversion. 
In  practice  two  degrees  can  be  made  out,  and  these 
can  be  easily  comprehended  by  a  reference  to  Figs. 
127  and  128. 

In  the  first  form  there  is  a  depression  of  one 
side  or  partial  inversion  ;  the  second  form  is  a  com- 
plete inversion.  When  the  vagina  is  also  inverted, 
the  condition  is  known  as  inversion  and  prolapsus. 

This  complication  occurs  as  a  rule  in  the  puer- 
peral state  only.  In  all  cases  of  inversion,  at  least 
at  the  time  when  this  accident  occurs,  enlargement 
and  relaxation  of  the  tissues  of  the  uterus  are  found. 
This  is  particularly  so  in  the  puerperal  state,  when  inversion  oc- 
curs most  frequently. 

Symptomatology. — The  severity  of  the  symptoms  depends  upon 
the  extent  of  the  inversion  and  the  sudden- 
ness with  which  it  occurs.  Partial  inversion, 
brought  about  gradually,  may  not  cause  sufi&- 
cient  disturbance  to  attract  attention.  The 
symptoms  of  shock  are  present  when  the  in- 
version occurs  suddenly,  as  it  does  in  the  puer- 
peral state.  The  shock  and  pain  are  more 
marked,  as  a  rule,  when  the  inversion  is  accom- 
panied with  prolapsus.  In  a  few  recorded  cases, 
the  shock  alone  proved  fatal. 


Fig.  127.— Partial 
inversion  (Thom- 
as). 


If  there  is  great 


Fig.  128.— Complete 
version  (Thomas). 


272  DISEASES  OF  WOMEN. 

haemorrhage  as  well  as  shock,  the  patient  is  more  likely  to  suc- 
cumb. 

Haemorrhage  occurs  when  the  inversion  is  incomplete  as  well 
as  when  complete,  especially  at  the  time  when  the  accident  takes 
place.  Tlie  presence  of  the  uterus  in  the  vagina  causes  disturbance 
of  the  bladder  and  rectum,  by  pressure. 

These  are  the  symptoms  which  occur  in  acute  inversion,  and  if 
the  patient  passes  safely  through  this  stage  then  the  symptoms  of 
chronic  inversion  aj^pear. 

In  complete  inversion  after  the  uterus  has  fully  contracted,  the 
haemorrhage  is  not  profuse,  except  at  the  menstrual  periods,  when 
there  may  be  menorrhagia.  This  is  generally  a  sero-sanguinolent 
discharge  for  the  iirst  week  or  even  later,  then  the  irritation  may 
cause  congestion,  ulceration,  and  general  inflammation  of  the  vagina 
and  mucous  membrane  of  the  uterus,  and  a  consequent  leucorrhoea 
and  purulent  discharge. 

If  the  uterus  remain  outside  of  the  vagina  it  usually  becomes 
dry  from  exposure  to  the  air,  but  it  also  becomes  abraded  in  places 
and  finally  ulceration  occurs.  Whether  the  uterus  remain  in  the 
vagina  or  becomes  completely  prolapsed,  the  inflammation,  ulcera- 
tion, haemorrhage,  and  the  purulent  discharge  which  arise  there- 
from may  break  down  the  general  health  of  the  patient  and  the  case 
terminate  fatally. 

Throughout  all  this  there  is  pelvic  pain  and  tenesmus. 

Physical  Signs. — The  diagnosis  (which  is  not  by  any  means 
easy  in  all  cases)  depends  largely  upon  the  physical  signs.  These 
differ  somewhat  in  recent  cases  and  in  those  of  long  standing. 
When  the  inversion  occurs  after  labor,  the  bimanual  touch  will 
reveal  two  very  important  facts.  The  uterus  is  not  found  in  its 
position  behind  the  pubes,  but  occupies  the  pelvic  cavity,  and  can 
be  outlined  in  the  vagina.  By  moving  the  uterus  between  the 
two  hands,  the  fundus  and  body  will  be  found  below  in  the  true 
pelvis,  while  instead  of  the  fundus  being  found  above,  a  depres- 
sion in  the  uterus  can  be  felt  at  the  superior  strait.  If  the  vagi- 
nal touch  alone  is  relied  upon,  the  condition  will  be  taken  for  the 
coming  placenta.  The  placenta  being  attached  to  the  uterus,  as  it 
usually  is  at  this  time,  obscures  the  uterus,  but  upon  trying  to  re- 
move it  from  the  vagina  by  hooking  down  one  of  its  edges  with  the 
finger,  the  solid  uterus  will  be  found  above  the  placenta,  the  two 
being  united,  but  easily  separated.  While  this  exploration  and  re- 
moval of  the  placenta — if  it  is  present — are  going  on,  the  left  hand 
is  placed  upon  the  abdomen,  and  the  absence  of  the  uterus  above  is 


INVERSION   OP  THE  UTERUS.  273 

observed,  as  already  stated.  Passing  the  linger  above  the  mass  in 
the  vagina,  in  search  of  the  walls  of  the  cervix  and  the  os  uteri,  a 
furrow  is  felt  which  shows  that  the  walls  of  the  vagina  and  uterus 
are  continuous,  and  that  there  is  no  opening  into  the  cavity  of  the 
uterus. 

These  signs  will  suffice  for  any  one  who  is  familiar  with  the 
normal  condition  of  the  parts  in  labor,  to  make  a  diagnosis.  In 
fact,  there  are  only  two  things  which  could  easily  be  mistaken  for 
inversion,  a  fibrous  tumor  and  the  presenting  membranes  in  a  case 
of  tmns.  The  latter  could  be  made  out  by  palpating  the  abdomen 
and  finding  the  large  uterus  with  the  child,  and  the  other,  though 
less  easily,  could  be  detected  by  the  presence  of  the  uterus  behind 
the  pubes  and  the  presence  of  the  uterine  canal  which  could  be  fol- 
lowed by  the  touch  beyond  the  tumor. 

These  physical  signs  should  be  sufficient  to  suggest  the  diagnosis, 
which  can  be  confirmed  by  restoring  the  inversion. 

This  is  easily  accomplished  by  any  one  familiar  with  obstetric 
manipulations.  When  there  is  complete  prolapsus,  as  well  as  inver- 
sion, the  diagnosis  can  be  made  by  inspection.  The  form  of  the 
tumor,  the  appearance  of  its  mucous  membrane,  the  presence  of  the 
j)lacenta,  or,  in  case  that  it  has  been  detached,  the  irregular  appearance 
of  the  placental  site  compared  with  the  rest  of  the  membrane,  and 
the  contractions  of  the  uterus,  which  can  be  noticed  while  handling 
the  parts,  are  quite  sufficient  to  settle  the  diagnosis. 

In  old  cases,  in  which  the  uterus  has  become  reduced  to  its  origi- 
nal size  by  involution,  the  diagnosis  is  not  so  easy  as  in  recent  cases, 
and  yet,  by  the  aid  of  the  sound  and  the  bimanual  touch,  the  diag- 
nosis can  be  made  with  certainty  in  the  great  majority  of  cases. 

By  the  touch  the  round  tumor  is  found  projecting  into  the  va- 
gina, and  the  lips  of  the  os  externum  can  be  distinguished  surround- 
ing the  tumor.  The  fornices  can  sometimes  be  made  out  also.  In 
most  of  the  cases  that  I  have  seen  the  cervix  was  thinned  out  so 
that  its  walls  felt  as  if  continuous  with  the  vagina,  and  the  fornices 
were  also  obliterated.  In  either  condition  the  evidence  is  in  favor 
of  inversion,  but  when  the  cervix  can  be  found  the  evidence  is  more 
valuable,  especially  if  the  finger  can  be  passed  up  into  the  cervix 
between  its  walls  and  the  body  of  the  uterus.  There  the  mucous 
membrane  of  the  cervix  can  be  felt  reflected  upon  the  tumor  to  the 
same  extent  all  around. 

These  signs  can  be  made  out  by  the  vaginal  touch.  The  biman- 
ual touch  is  still  more  satisfactory.  By  that  method  the  uterus  can 
be  raised  up  in  the  pelvis  by  the  finger  or  fingers  of  one  hand  in  the 

19 


274 


DISEASES  OF   WOMEN. 


vagina,  while  with  the  other  hand  a  body  with  a  depression  in  its 
center  can  be  felt  through  the  wall  of  the  abdomen.  In  spare  pa- 
tients with  relaxed  abdominal  muscles  the  bimanual  touch  will  usu- 
ally suffice  to  make  the  diagnosis  quite  positive. 

In  doubtful  cases  the  uterus  may  be  drawn  down  with  a  tenacu- 
lum or  pressed  down  by  a  hand  upon  the  abdomen,  while  a  rectal 
examination  with  the  index-finger  of  the  other  hand  is  made.  In 
this  way  the  fingers  of  the  two  hands  may  be  made 
to  meet  above  the  uterus,  and  at  the  same  time  the 
finger  in  the  rectum  may  detect  the  cup-shaped  end 
of  the  uterus  above.  In  case  the  bimanual  touch 
is  not  practicable,  owing  to  the  patient  being  very 
stout,  or  the  abdominal  muscles  unyielding,  the  same 
signs  can  be  obtained  by  passing  a  sound  into  the 
bladder  and  turning  it  backward  until  it  meets  the 
finger  in  the  rectum  above  the  uterus. 

To  facilitate  either  or  both  of  these  methods  of 
examination  by  the  touch,  the  uterus  may  be  drawn 
downward  by  a  noose  made  of  tape  or  rubber  passed 
around  the  cervix,  as  recommended  by  Barnes. 

Chronic  inversion  is  likely  to  be  mistaken  for 
fibrous  polypus  of  the  uterus.     A  number  of  mis-      ^^)- 

takes  of  this  kind  are  on  record,  but  most  of  them 
occurred  before  the  time  when  the  uterine  sound 
and  the  bimanual  touch  were  employed  for  diag- 
nostic purposes.  The  diiierentiation  can  usually  be 
made  by  the  methods  of  examination  already  de- 
scribed. 

In  polypus,  the  uterine  sound  can  be  passed  be- 
yond the  tumor  into  the  uterus  above,  whereas,  in 
inversion,  the  progress  of  the  sound  is  arrested  at 
the  neck  of  the  uterus.  The  bimanual  touch,  rec- 
tal touch,  and  vesico-rectal  examination,  reveal  tlie 
uterus  above  the  tumor.  The  inverted  uterus  is 
tender,  the  polypus  is  not.  This  sign  is  of  much 
value.  By  seizing  the  tumor  and  turning  it  around 
it  will  move  in  the  cervix  if  it  is  a  polypus.  The 
two  surfaces  will  glide  backward  and  forward  upon 
each  other,  Init  in  inversion  no  such  motion  can  be 
produced.  Incomplete  inversion  is  not  easily  diag- 
nosticated under  the  most  favorable  circumstances.  To  distinguish 
partial  inversion  from  an  intra-uterine  fibroid  of  small  size  is  next  to 


Fig.  129.— Polypus 
siraulating  partial 
inversion  (Thom- 


FiG.  130.— I'ohpus 
simulating  com- 
plete inversion 
(Thomas). 


INVERSION  OF  THE  UTERUS.  275 

impossible.  Fortunately,  sucli  a  diagnosis  is  not  imperative,  because 
active  treatment  is  not  often  called  for  in  these  incomplete  and 
doubtful  cases. 

Prognosis. — Inversion  is  always  a  grave  condition.  If  it  does 
not  prove  fatal  at  first  from  shock  and  haemorrhage,  it  becomes  a 
continuous  trouble,  which  either  gradually  undermines  the  general 
health,  and  thereby  shortens  life,  or  else  keeps  the  subject  in  a  state 
of  impaired  usefulness  and  ill  health.  There  is  no  certain  tendency 
to  natural  recovery,  and  although  quite  a  number  of  cases  have  been 
recorded  in  which  spontaneous  replacement  of  the  uterus  was  said  to 
have  taken  place,  such  an  occurrence  must  be  very  rare.  From  the 
fact  that  most  of  these  cases  are  recorded  by  the  older  authors,  it  is 
possible  that  in  some  of  them  the  diagnosis  was  incorrect.  One  thing 
is  certain,  no  such  fortunate  termination  should  be  exj^ected  or  rehed 
upon.     Without  treatment  the  condition  wiU  probably  continue. 

The  prognosis  is  rendered  more  grave  by  the  fact  that  the 
treatment  is  not  without  danger. 

There  are  several  methods  of  treating  inversion,  but  neither  of 
them  is  wholly  safe.  This  statement  applies  to  chronic  inversion. 
When  the  inversion  occurs  during  labor,  immediate  replacement  is 
easy  and  not  attended  with  any  great  risk.  The  dangers  in  restor- 
ing an  old  inversion  are  from  inflammation  and  septicsemia,  pro- 
duced by  the  injuries  to  the  uterus,  vagina,  and  adjoining  parts 
during  the  violent  efforts  necessary  to  accomphsh  the  object.  These 
dangers  are  greatly  increased  hj  unskillful  operating,  still  unfortunate 
results  have  occurred  in  the  practice  of  the  most  skillful  surgeons. 

Causation. — The  conditions  which  predispose  to  inversion  are 
enlargement  of  the  uterus  and  relaxation  of  its  tissues.  These  are 
best  illustrated  in  the  puerperal  state.  Inversion  can  not  take  place 
in  a  normal  non-puerperal  uterus.  The  condition  of  the  uterus  im- 
mediately after  the  delivery  of  the  child  is  most  favorable  to  the 
accident,  and  it  is  at  this  time  and  under  these  circumstances  that 
inversion  most  frequently  occurs. 

Predisposing  causes,  other  than  pregnancy  or  parturition,  are 
known,  but  they  are  oj)erative  in  bringing  about  a  condition  of  en- 
largement of  the  uterus  and  relaxation  of  its  tissues.  These  are 
distention  of  the  uterus  from  tumors  or  fluids.  The  relaxation  of 
tissues  which  is  found  in  imperfect  involution  and  prolapsus  is  also 
given  as  a  predisposing  cause,  but  I  have  not  seen  the  record  of  any 
case  which  could  be  clearly  traced  to  this  cause. 

To  briefly  restate  this  matter,  the  tendencies  to  inversion  depend 
upon  enlargement,  distention,  and  relaxation.     The  exciting  causes 


276  DISEASES  OF  WOMEN. 

are  traction  or  pressure  upon  tlie  fundus  uteri  when  it  is  in  a  con- 
dition favorable  to  inversion.  The  direct  causes  are  traction  upon 
the  umbilical  cord  or  pressure  upon  the  fundus  uteri  at  the  moment 
when  the  child  is  expelled,  or  sudden  delivery  of  the  child,  either 
by  traction  or  the  natural  muscular  efforts.  Muscular  efforts,  when 
there  is  relaxation  of  the  uterus,  are  mentioned  as  a  cause,  and  cases 
are  recorded  in  which  inversion  is  said  to  have  occurred  in  that  way, 
but  that  cause  must  be  seldom  operative.  Prolapsus  uteri  is  also 
credited  with  having  some  causative  relation  to  inversion,  but  I 
liave  no  knowledge  on  this  subject.  Next  to  parturition  come  intra- 
uterine tumors  in  the  causation  of  inversion.  All  the  cases  which 
have  come  directly  under  my  own  observation,  or  that  have  come  to 
my  knowledge  indirectly  through  competent  contemporary  authori- 
ties, have  been  clearly  traceable  to  parturition  or  fibrous  polypi. 

The  conditions  are  alike  in  pregnancy  and  intra-uterine  tumors, 
so  far  as  the  uterus  is  concerned  in  the  predisposition  to  inversion. 
There  is  enlargement  of  the  uterus  with  relaxation  followed  by 
muscular  contraction.  During  the  growth  of  the  tumor  the  uterus 
increases  in  size,  and  finally  endeavors  to  expel  the  growth,  and 
when  the  muscular  contractions  are  going  on  the  fundus  uteri  is 
dragged  downward  by  the  pedicle  of  the  tumor.  In  this  way  all 
the  predisposing  and  mechanical  conditions  are  j^resent  which  are 
most  competent  to  cause  inversion. 

Treatment. — There  are  several  methods  of  managing  inversion. 
Of  course  the  indications  are  to  restore  the  uterus  to  its  proper  rela- 
tions. This  is  often  difiicult  in  chronic  inversion,  and  sometimes 
impossible,  hence  other  means  must  be  employed  to  give  all  relief 
possible. 

In  case  replacement  can  not  be  accomplished,  the  most  promi- 
nent symptoms  should  be  relieved  by  treatment ;  hiemorrhage  should 
be  controlled  by  astringents  and  inflammation  should  be  reduced  by 
appropriate  care.  Inversion  can  be  successfully  treated  if  seen  im- 
mediately after  it  occurs.  The  method  of  operating  is  to  grasp  the 
uterus  in  the  right  hand,  and  carry  it  upward  until  the  cervix  can 
be  felt  with  the  left  hand  through  the  abdominal  wall ;  counter- 
pressure  is  then  made  while  the  fundus  uteri  is  being  forced  upward 
with  the  right  hand  in  the  vagina.  The  abdominal  walls  being  thor- 
oughly relaxed,  as  they  are  immediately  after  confinement,  the  bi- 
manual manipulations  are  comparatively  easy.  The  os  uteri  can  be 
felt  with  the  left  hand,  and  by  pressing  the  abdominal  wall  down 
into  it  with  the  fingers  it  is  dilated,  and  when  the  fundus  is  restored 
far  enough  to  engage  in  the  os,  the  lips  of  the  cervix  can  be  pushed 


INVERSION  OF  THE  UTERUS.  277 

over  the  fundus,  in  the  same  way  that  they  are  pushed  over  the  head 
of  the  child  in  delivery. 

Cases  of  Recent  Inversion. — I  have  seen  four  cases  of  inversion 
soon  after  they  occurred,  one  in  my  own  practice  and  three  in  con- 
sultation. 

Two  of  these  were  inversion  with  complete  prolapsus,  and  the 
other  two  were  uncomplicated.  My  own  case  was  that  of  a  strong 
young  woman  in  her  second  confinement.  The  pelvic  outlet  was 
rather  narrow,  and  the  perineeum  rigid,  so  that  the  pains  which  ex- 
pelled the  head  were  most  powerful,  especially  the  last  one.  The 
moment  that  the  head  passed  the  perinseum  the  whole  child  was 
expelled  with  extraordinary  force.  While  the  nurse  rested  her  hand 
upon  the  abdomen  I  tied  the  cord,  and  then  I  found  the  placenta 
presenting  at  the  vulva.  I  passed  my  finger  up  to  bring  the  edge 
down  and  then  deliver  it,  but  I  found  a  hard  body  above  to  which  it 
was  attached.  I  then  passed  my  left  hand  over  the  abdomen,  and 
found  that  the  uterus  was  not  there.  Inversion  was  suspected,  and 
I  at  once  separated  and  removed  the  placenta,  which  was  very  easily 
done  in  this  case,  and  then  with  bimanual  manipulation  restored  the 
uterus  with  the  greatest  facility.  The  removal  of  the  placenta  and 
the  reduction  of  the  uterus  occupied  but  a  moment.  The  patient  did 
not  apparently  suffer,  but  I  think  that  there  was  slight  shock  and 
consequent  anaesthesia,  so  that  the  reduction  was  painless  and  finished 
before  she  reacted. 

I  found  I  could  grasp  the  fundus  easily,  and  by  making  firm  press- 
ure upon  one  comer  with  my  thumb  and  upon  the  other  with  the 
middle  finger,  and  thus  raising  the  whole  uterus  up  until  I  could  feel 
the  OS  with  the  fingers  of  the  left  hand,  the  pressure  and  counter- 
pressure  effected  the  reduction  with  ease  and  rapidity. 

I  found  that  the  reduction  of  one  horn  first,  as  recommended  by 
Dr.  Noeggerath,  answered  well,  first  because  the  horn  was  more 
easily  brought  under  pressure,  and  also  because  it  appeared  to  yield 
most  readily.  In  grasping  the  uterus  the  thumb  naturally  rests 
upon  one  horn,  and  by  making  firm  pressure  at  that  part,  which  is 
more  convenient  than  to  press  upon  the  center  of  the  fmidus,  it 
appears  to  be  the  natural  way  of  effecting  reduction  by  the  unaided 
hand.  The  hand  was  made  to  follow  up  the  reduction,  so  that  when 
it  was  completed  the  hand  was  fully  within  the  utenis,  and  it  was  left 
there,  and  pressure  upon  the  uterus  with  the  left  hand  upon  the 
abdomen  was  made  until  the  uterus  contracted  and  the  hand  was 
expelled.  This  was  the  part  of  the  procedm-e  which  required  the 
most  time,  owing  to  the  uterus  being  slow  to  contract. 


278  DISEASES  OF  WOMEN. 

The  three  other  cases  were  seen  in  the  practice  of  others.  One 
that  I  saw  with  Dr.  A.  R.  Matheson,  was  a  complete  prolapsus  as 
well  as  inversion.  I  saw  the  patient  in  about  half  an  hour  after  the 
inversion  occurred.  There  was  considerable  shock,  and  the  doctor 
was  obliged  to  liold  the  uterus  with  the  placenta  attached  in  the  firm 
grasp  of  both  hands  to  prevent  hsemorrhage.  The  prolapsus  was 
reduced  first  and  then  the  inversion,  in  the  same  waj  and  in  about 
the  same  time  as  the  case  just  described.  I  saw  another  case  of  in- 
version and  prolapsus  with  Dr.  Bliss.  It  was  of  three  days'  stand- 
ing. The  doctor  did  not  attend  in  confinement,  but  was  called  to 
see  the  j)atient  because  of  the  inversion.  When  I  saw  her  she  was 
exceedingly  weak.  The  pulse  140,  and  feeble.  She  was  anaemic, 
and  the  abdomen  greatly  distended  and  tender  to  the  touch.  The 
uterus  was  resting  between  the  limbs,  and  parts  of  the  mucous  mem- 
brane here  and  there  were  in  a  sloughing  condition,  and  other  por- 
tions were  dry  and  glazed  looking.  Vaseline  was  applied  over  the 
whole  surface,  and  the  uterus  first  pushed  up  into  the  vagina  and 
then  grasped  with  the  hand,  and  the  inversion  reduced.  The  opera- 
tion in  this  case  was  more  difiicult  and  prolonged.  Owing  to  the 
tympanitic  state  of  the  abdomen  it  was  difiicult  to  make  proper 
pressure  upon  the  lips  of  the  cervix,  and  that  was  a  cause  of  delay. 
The  extreme  depression  of  the  patient  (while  it  raised  a  doubt  as  to 
her  being  able  to  stand  the  operation  of  reduction)  gave  that  com- 
plete relaxation  and  general  anaesthesia  which  was  favorable.  No 
anaesthetic  was  given.  In  about  ten  minutes  the  reduction  was 
effected.     The  patient  recovered. 

One  other  case  I  saw  with  Dr.  Bodkin.  The  inversion  occurred 
at  two  o'clock,  and  three  hours  later  it  was  reduced.  There  was 
some  excitement  of  the  pulse,  and  the  patient  had  pelvic  ])ain. 
There  was  very  little  haemorrhage,  but  there  had  been  considerable 
at  the  confinement.  Chloroform  was  administered,  and  the  reduc- 
tion was  accomplished  by  the  same  method.  More  time  was  required 
than  in  either  of  the  other  cases,  because  there  was  more  contraction 
of  the  uterus,  but  by  means  of  upward  pressure  and  counter-pressure 
upon  the  lips  of  the  cervix  the  reduction  was  accomplished  in  a  short 
time. 

Chronic  inversion  is  far  more  difficult  to  manage  than  recent  in- 
version. In  fact,  when  the  inversion  has  existed  long  enough  to 
permit  the  uterus  to  regain  its  original  size,  or  nearly  so,  by  involu- 
tion, and  has  contracted  firmly,  its  reduction  is  always  difficult,  and 
sometimes  impossible.  This  has  led  surgeons  to  devise  several 
methods  of  reducing  this  inversion  under  these  circumstances. 


INVERSION  OF   THE  UTERUS.  279 

Dr.  Thomas  has  classiiied  tliese  methods  as  follows :  Methods 
of  effecting  gradual  reduction  and  methods  of  effecting  rapid  reduc- 
tion. The  method  of  reduction  by  taxis  is  the  oldest  and  most  re- 
liable, and  should  be  tried  first  in  all  cases,  because,  if  it  fails,  the 
gradual  reduction  may  be  tried  subsequently,  providing  that  the 
taxis  is  not  so  violent  and  prolonged  as  to  cause  fatal  inflammation. 

There  are  several  ways  of  applying  taxis,  but  only  two  ways  of 
attaining  the  desired  end.  The  principle  of  the  one  is  to  reduce 
first  that  portion  which  was  last  inverted,  and  the  other  is  to  reduce 
the  fundus  first  and  dilate  the  cervix  at  the  same  time,  so  that  the 
portion  first  inverted  is  first  reduced.  To  some  extent  both  objects 
may  be  attained  at  the  same  time  by  so  manipulating  that  both 
changes  of  position  may  go  on  together.  The  method  of  operating 
is  as  follows :  The  patient  should  be  placed  upon  the  operating 
table  in  the  dorsal  position,  and  the  surgeon's  hand  carefully  in- 
troduced into  the  vagina.  It  is  necessary  to  dilate  the  vagina,  in 
the  great  majority  of  cases,  in  order  to  admit  the  hand.  Some- 
times the  dilatation  is  difiicult  to  accomj^lish  with  the  hand  without 
rupturing  the  vagina.  When  this  is  the  case,  dilatation  as  a  pre- 
liminary measure  should  be  accomplished  by  stretching  with  the 
speculum  and  the  inflatable  rubber  bag.  The  right  hand  is  introduced 
into  the  vagina  and  the  uterus  grasped  with  the  thumb  and  fingers. 
The  uterus  is  compressed  and  at  the  same  time  carried  upward,  and 
held  against  the  left  hand,  which  makes  the  counter-pressure.  The 
manipulations  with  the  right  hand  should  be  so  directed  that  one  or 
both  horns  should  be  reduced  first.  The  cervix  should  be  dilated, 
and  reduction  begun  at  that  point  at  the  same  time  that  reduction 
of  the  horn  is  effected.  Fortunately,  the  efforts  to  accomplish  the 
one  favor  the  other. 

This  method  of  ]^oeggerath's,  which  has  already  been  discussed, 
is  that  which  I  prefer,  but  there  are  certain  modifications  which  are 
of  value  in  certain  cases,  and  should  be  employed  when  failure  of 
the  one  method  makes  the  trial  of  the  modified  methods  necessary. 
For  example,  Dr.  Thomas  has  employed  a  cone  of  wood  in  place  of 
the  left  hand  for  dilating  the  cervix.  In  thin  patients  this  can  be 
inserted  into  the  ring  of  the  cervix,  which  can  be  felt  through  the 
abdominal  walls,  and  gradually  forced  into  the  cervix  until  suflicient 
dilatation  is  obtained.  Barren  placed  the  fingers  around  the  body  of 
the  uterus  and  the  thumb  upon  the  fundus,  and  forced  the  cervix 
against  the  sacrum  to  secure  counter-pressure. 

Courty's  method  consists  in  using  the  index  and  middle  fingei's 
of  the  left  hand  in  the  rectum,  to  dilate  the  cervix  and  make  coun- 


280  DISEASES  OF  WOMEN. 

ter-pressnre.  This  method  of  using  the  left  hand  combined  with 
the  method  of  Dr.  Noeggerath  is  highly  commended  by  Dr.  T.  G. 
Thomas.  Dr.  Emmet  describes  his  method  as  follows  :  "  In  1865  I 
succeeded  in  effecting  a  reduction  by  passing  my  hand  into  the  va- 
gina, and,  with  the  fingers  and  thumb  encircling  the  portion  of  the 
body  close  to  the  seat  of  inversion,  the  fundus  was  allowed  to  rest 
in  the  palm  of  the  hand.  This  portion  of  the  body  was  firmly 
grasped,  pushed  upward,  and  the  fingers  were  then  immediately 
separated  to  their  utmost ;  at  the  same  time  the  other  hand  was  em- 
ployed over  the  abdomen  in  the  attempt  to  roll  out  the  part  form- 
ing the  ring,  by  sliding  the  abdominal  parietes  over  its  edge.  This 
manoeuvre  was  repeated  and  continued.  At  length,  as  the  trans- 
verse diameter  of  the  uterine  cervix  and  os  was  increased  by  lateral 
dilatation  with  the  outspread  fingers,  the  long  diameter  of  the  body 
became  shortened,  and  the  degree  of  inversion  proportionately  less- 
ened. After  the  body  had  advanced  well  within  the  cervix,  steady 
upward  pressure  upon  the  fundus  was  applied  by  the  tips  of  all  the 
fingers  brought  together." 

This  method,  which  appears  to  me  like  Yandel's,  is  natural  in 
theory,  but  in  trying  it  I  have  found  that  I  could  not  separate  the 
fingers  to  any  extent,  owing  to  the  fact  that  the  extensor  muscles  are 
feeble  in  their  action,  and  not  capable  of  doing  more  than  resisting 
the  pressiu'e  of  the  vagina. 

Dr.  Emmet  also  commends  the  closure  of  the  cervix  with  silver 
sutures  in  cases  where  the  reduction  can  not  be  completed.  He 
gives  a  diagram  representing  the  cervix  as  being  about  three  times 
as  long  as  the  body,  and  drawn  over  the  fundus  and  held  there  by 
sutures.  I  have  never  practiced  this  treatment  for  the  reason  that 
in  all  the  cases  in  which  I  have  been  able  to  get  the  body  and  fun- 
dus reduced  wholly  within  the  cervix,  the  complete  reduction  has 
been  easily  and  speedily  accomplished.  Again,  I  can  not  see  how 
sutures  of  any  kind  would  resist  the  pressure  of  a  partially  inverted 
uteras,  w^th  a  strong  tendency,  which  there  always  is,  to  become 
further  inverted. 

Repositors  have  been  used  to  aid  in  the  taxis  by  De  Paul,  Avel- 
ing,  White,  and  others.  The  most  useful  of  these,  and  one  that 
fulfills  the  requirements  is  that  invented  by  Dr.  John  Byrne,  of 
Brooklyn.  It  consists  of  a  cup  and  stem  with  a  movable  plug  or 
button  in  its  center.  The  button  forms  the  bottom  of  the  cup  when 
it  is  placed  over  the  uterus,  and  while  the  cup  is  in  place  the  plug 
is  pushed  forward  by  the  screw  in  the  handle  against  the  fundus, 
and  in  that  way  makes  the  required  upward  pressure. 


INVERSION  OF  THE  UTERUS. 


281 


Fig.  131. — Byrne's  method  of  reduction. 


Fig.  131  shows  Dr. 
Byrne's  repositor  as  used, 
and  its  cup  or  bell-shaped 
instrument  with  the  plug 
and  screw  adjustment  for 
making  counter  -  pressure 
and  dilatation  of  the  cervix. 
A  piston  in  the  lower  cup 
pushes  the  fundus  up. 
There  are  a  number  of  ad- 
justable cups  which  can  be 
adapted  to  the  require- 
ments of  different  cases. 

Cases  are  sometimes  met 
which  can  not  be  restored 
by  taxis.  Resort  must  then 
be  had  to  such  means  as 
gradual  reduction  by  con- 
tinuous pressure.  This  is 
effected  by  a  cup  and  stem 
(Fig.  132)  which  are  held  in  place  by  a  perineal  band  of  rubber  or 
elastic  fastened  to  a  bandage  applied  around  the  pelvis.  When  using 
this  instrument  care 
must  be  taken  to 
keep  the  uterus  in 
the  line  of  press- 
ure. When  the  va- 
gina is  relaxed  the 
uterus  may  fall 
backward  or  for- 
ward out  of  the 
line  of  pressure  ; 
this  can  be  avoided 
by  using  a  tampon 
around  the  uterus, 
which  may  be  worn 
for  two  days  if  no 
great  distress  is 
caused  by  it.  It 
should  be  examined 
from  time  to  time, 

and  if  there  is  much    Fig.  1 32.— Cup  pessary  to  exercise  gradual  pressure  (Thomas) 


282  DISEASES   OF  WOMEN. 

irritation  the  instrument  should  be  remoyed  and  vaginal  injections 
used  until  relief  is  obtained,  and  the  use  of  the  instrument  may  be 
again  resumed. 

The  rubber  bag  tilled  with  water  answers  a  very  good  purpose. 
To  apply  this,  the  patient  should  be  placed  in  Sims's  position,  and 
through  the  speculum,  the  upper  portion  of  the  space  between  the 
uterus  and  vagina  should  be  tilled  with  prej^ared  wool ;  then  the  bag 
should  be  introduced  between  the  fundus  uteri  and  the  pelvic  floor, 
and  distended  with  water.  A  firm  perineal  band  is  then  used  to 
support  the  pelvic  floor.  Dr.  Thomas  recommends  a  strip  of  adhe- 
sive plaster  for  the  perineal  band,  one  end  being  fastened  to  the 
sacrum  and  the  other  to  the  abdomen,  with  two  openings,  one  for 
the  tube  of  the  bag,  and  the  other  opposite  the  urethra  to  permit 
urination.  I  prefer  the  ordinary  muslin  or  elastic  band,  because  it 
is  more  easily  removed  and  readjusted.  The  degree  of  pressure  and 
the  time  which  it  should  be  continued  must  depend  upon  the  re- 
sults. 

If  there  is  much  pain  or  irritation  the  treatment  must  be  sus- 
pended. The  combination  of  elastic  pressure  and  taxis  has  been 
employed  with  advantage.  After  the  pressure  has  been  used  for  a 
time  taxis  should  be  tried,  and  in  case  this  fails  the  elastic  pressure 
should  be  again  attempted.  Care  must  be  exercised  in  the  use  of 
taxis — it  should  not  be  too  violent  or  long-continued  ;  this  must  be  de- 
cided by  the  operator  in  each  case. 

Dr.  Charles  Martin,  of  France,  succeeded  by  using  a  stream  of 
odd  water  projected  against  the  fundus  uteri,  through  the  speculum. 
This  he  employed  twice  a  day.  The  stream  was  thrown  wdth  con- 
siderable force ;  he  also  filled  the  speculum  with  cold  water,  and 
kept  the  uterus  in  it  three  or  four  minutes.  Dr.  T.  G.  Thomas, 
from  whose  work  I  take  the  above  statement,  approves  of  this 
method. 

Dr.  Thomas  has  devised  another  method,  wdiich  I  understand 
he  employs  or  advises  where  other  methods  fail.  The  following  is 
taken  from  his  work  on  diseases  of  women :  "  Thomas's  method 
consists  in  abdominal  section  over  the  cervical  ring,  dilatation  Avith 
a  steel  instrument,  made  like  a  glove-stretcher,  and  reposition  of  the 
inverted  uterus  by  any  one  of  the  methods  mentioned,  by  the  hand 
in  the  vagina.     Fig.  133  will  render  this  clear. 

"  Tliis  procedure,  let  it  be  remembered,  is  not  offered  as  a  method 
of  treating  inversion  of  the  uterus,  but  as  a  substitute  for  amputa- 
tion. Few  cases  will,  I  think,  resist  elastic  pressure  and  judicious 
taxis ;  but  that  some  will'  do  so  can  not  be  questioned.     It  is  to 


INVERSION  OF  THE  UTERUS. 


283 


save   these   few   cases   from   amputation  that  I  suggest  abdominal 
section. 

"  One  of  the  cases  operated  on  in  this  way  has  proved  fatal.  Let 
it  not  be  forgotten  that  a  certain  number  of  these  cases  treated  by 
elastic  pressure  and  by  taxis  likewise  do  so,  for,  as  in  my  second 
case,  these  operations  are  often  performed  upon  exsanguinated 
women  whose  blood  is  impoverished.  One  instance  of  death  after 
reduction  by  elastic  pressure  is  recorded  by  Dr.  Tait  in  the  eleventh 
volume  of  the  '  London  Obstetrical  Transactions,'  while  one  of  the 

earliest  cases  on  record 
reduced  by  taxis — that  of 
Dr.  White,  of  Buffalo, 
likewise  ended  fatally." 

One  other  method  is 
worthy  of  mention,  name- 
ly, that  of  Dr.  Brown,  of 
Baltimore.  He  makes  a 
free  incision  in  the  fun- 
dus uteri,  and  through  the 
opening  thus  made  he 
stretches  the  cervix  and 
then  reduces  by  taxis.  In 
case  of  failure  of  all  ef- 
forts, hysterectomy  may 
be  performed.  This,  I 
consider  advisable,  if  the 
patient  is  near  to  or  past  the  menopause,  but  it  should  not  be  un- 
dertaken until  all  other  methods  have  failed. 

There  are  several  methods  of  amputating  the  inverted  uterus. 
Dr.  McClintock  applied  a  string  ligature  around  the  highest  portion 
which  strangulated  the  uterus,  and  in  two  or  three  days  when  de- 
composition of  the  tissues  began,  he  amputated.  Hegar  accom- 
plished the  same  object  by  j)assing  strong  sutures  through  the  cer- 
vix, and  after  drawing  them  tight  enough  to  close  the  vessels  and 
close  the  peritoneal  cavity,  the  body  was  amputated. 

It  will  suffice  to  simply  mention  amputation  without  giving  elab- 
orate details.  It  was  frequently  practiced  in  the  past,  but  is  sel- 
dom heard  of  now.  Other  methods  succeed,  and  with  the  method 
of  Thomas  in  reserve — in  case  pressure  and  taxis  fail — amputation 
will  seldom,  if  ever  be  called  for.  Cases  might  be  quoted  to  illus- 
trate the  treatment  of  chronic  inversion,  but  they  would  add  noth- 
ing of  value  to  the  methods  of  operating  given  above. 


Fig    133. — Replacement  of  uterus  by  dilatation 
through  abdomen.     (Thomas.) 


CHAPTER  XVII. 

DISLOCATIONS    OF    THE    UTEKUS. 

The  uterus  is  peculiarly  subject  to  pliysiological  changes  of 
position.  The  bladder  in  front  causes  the  uterus  to  move  forward 
and  backward  according  to  its  dilatations  and  contractions.  In  a 
similar  but  much  less  extensive  way,  distention  of  the  rectum  acts 
to  push  the  uterus  forward.  The  abdominal  pressure  from  above  is 
constantly  changing,  and  is,  therefore,  constantly  affecting  the  posi- 
tion of  the  uterus  less  or  more.  The  movements  of  the  uterus 
under  the  influence  of  the  ever  varying  degrees  of  abdominal  press- 
ure are  easily  observed  by  watching  the  anterior  vaginal  w^all  and 
uterus  through  a  Sims's  speculum  in  the  living  subject.  There  is 
an  up  and  down  motion,  very  limited  but  constant,  caused  by  ordi- 
nary respiration,  and  under  extra  exertion,  such  as  coughing,  the 
displacement  becomes  very  marked. 

Below  there  is  the  pelvic  floor,  which  has  least  of  all  to  do  with 
changing  the  position  of  the  utenis,  and  yet  much  to  do  in  counter- 
acting the  inclinations  to  displacement  produced  by  other  influ 
ences. 

These  changes  of  position,  when  limited  in  degree,  are  physio- 
logical, the  organ  promptly  returning  to  its  original  position  as  soon 
as  the  displacing  influence  is  removed.  It  is  only  when  the  uterus 
remains  displaced  permanently  or  is  carried. far  beyond  the  physio- 
logical limits  that  the  dislocation  is  to  be  regarded  as  pathological. 
When  this  occurs,  the  malposition  gives  rise  to  suffering  from  de- 
ranged menstruation,  circulation,  and  innervation,  and  in  some  cases 
to  sterility.  Usually,  the  functions  of  the  bladder  and  rectum  are 
disturbed  and  the  general  system  suffers  from  reflex  influences.  It 
is  oftly  when  such  symptoms  as  these  are  present  that  displacements 
of  the  uterus  claim  the  attention  of  the  gynecologist. 

In  order  to  fully  comprehend  displacements  of  the  uterus  it  is 
very  necessary  that  the  normal  position  of  the  uterus  should  be 

284 


DISLOCATIONS   OF  THE   UTERUS. 


285 


clearly  understood,  and  this  can  only  be  attained  by  a  knowledge  of 
the  anatomy  of  the  pelvic  organs. 

Anatomy. — In  discussing  this  subject  attention  will  be  chiefly 
directed  to  the  position  of  the  uterus  in  the  pelvis,  its  relations  to 
neighboring  organs,  and  the  position  and  character  of  the  structures 
which  keep  it  in  position. 

One  would  naturally  turn  to  the  cadaver  in  the  hope  that  by 
careful  dissection  the  exact  position  of  the  uterus  could  be  deter- 
mined, but  after  life  is  extinct  the 
uterine  supports  lose  their  firm- 
ness, and  changes  of  position  usu- 
ally take  place.  Moreover,  it  fre- 
quently happens  that  the  pelvic  or- 
gans are  less  or  more  displaced 
toward  the  end  of  life,  so  that  a 
normal  state  of  the  parts  is  not 
often  found  in  the  cadaver.  Dis- 
section also  tends  to  displacement, 
no  matter  how  carefully  it  may  be 
performed.  To  obviate  this,  sec- 
tions of  the  frozen  subject  have 
been  made,  and  much  valuable  in- 
formation obtained  from  them. 
Still,  the  greater  part  of  useful  in- 
formation on  this  subject  must  be 
obtained  from  careful  and  oft-repeated  examinations  of  the  living 
subject.  With  information  obtained  from  all  these  sources  there  are 
still  diflierences  of  opinion  among  authors  on  certain  points. 

Under  the  circumstances,  in  place  of  giving  a  number  of  conflict- 
ing opinions,  it  will  be  better  to  give  the  views  which  I  have 
adopted  as  the  result  of  my  own  observations  on  the  living  subject, 
and  after  a  careful  investigation  of  the  views  of  others. 

In  the  first  place,  it  may  be  said  that  the  uterus  is  wholly  within 
the  true  pelvis. 

The  line  on  the  diagram  running  between  the  symphysis  pubis 
and  the  promontory  of  the  sacrum  divides  the  true  pelvis  from  the 
abdomen,  and  all  the  pelvic  organs,  the  uterus  included,  are  below  this 
plane,  the  superior  strait,  as  the  obstetricians  call  it  (Fig.  64).  The 
long  diameter  of  the  uterus  in  the  pelvis  corresponds  very  nearly  to 
the  axis  of  this  plane,  as  represented  by  the  line  (Fig.  134),  and  it  is 
equidistant  from  the  sides  of  the  pelvis. 

The  position  of  the  uterus  varies  from  time  to  time,  as  already 


Fig.  134. — Section  of  pelvis,  showing  it 
inclination  and  the  axis  of  the  inlet. 


286 


DISEASES  OF  WOMEN. 


stated,  but  in  all  its  changes  it  returns  to  the  axis  of  the  inlet  of  the 
pelvis,  slightly  behind  the  center  of  the  true  conjugate.  This  is  not 
mathematicallv  correct,  but  is  sufficiently  so  to  form  a  basis  from 
which  further  studies,  both  anatomical  and  clinical,  may  be  con- 
ducted. 

In  order  to  obtain  some  idea  of  the  position  of  the  uterus  and  the 
influences  which  the  other  pelvic  organs  have  in  changing  this  posi- 
tion, reference  should  be  made  to  Fig.  64,  which  shows  a  section  of 
the  normal  pelvis.     Fig.  135  shows  the  changes  in  the  position  of 


Fig.  ]  35. — The  normal  range  of  the  uterine  axis,  varying  according  to  the  distention  of 
the  bladder ;  a,  with  bladder  empty  ;  i),  with  bladder  full  (Van  der  Warker). 

the  uterus  during  the  several  degrees  of  distention  of  the  bladder. 
These  physiological  changes  should  be  noted  and  the  causes  which 
give  rise  to  them,  in  order  that  they  may  be  recognized  clinically. 
Next  in  the  order  of  inquiry  are  the  anatomical  structures  by  which 
the  uterus  is  held  in  position.     This  requires  a  consideration  of  the 


DISLOCATIONS  OF  THE  UTERUS. 


28T 


structural  associations  of  the  uterus  and  all  the  other  pelvic  organs 
and  tissues.  The  position  of  the  several  pelvic  organs  may  be 
given  in  a  general  way  as  follows :  The  uterus  in  the  center,  Fallo- 
pian tubes  and  ovaries  on  either  side,  the. bladder  in  front,  rectum 
behind,  and  the  vagina  below.  Covering  all  of  these,  except  the 
vagina,  is  the  peritonaeum,  which  is  the  chief  bond  of  union  be- 
tween the  upper  portions  of  the  pelvic  organs,  and  out  of  which 
are  formed  the  ligaments  which  have  much  to  do  in  keeping  the 
uterus  in  place.  The  peritonaeum,  while  it  covers  the  pelvic  organs, 
is  attached  to  the  bony  walls  of  the  pelvis  through  the  medium 
of  the  periosteum  and  areolar  tissue,  so  that  one  end  of  each  liga- 
ment may  be  said  to  have  an  attachment  to  the  inner  side  of  the 
pelvic  bones.  The  round  ligaments  are  anatomically  an  exception 
to  this  rule.     They  contain  muscular  tissue  in  considerable  quan- 


FiG.  136. — Diagram  of  the  uterine  ligaments  as  seen  on  looking  into  the  brim. 

B,  bladder. 

tity,  and  are  really  outgrowths  from  the  uterus  in  the  form  of 
round  cords,  which  start  from  the  uterus  near  the  proximate  ends  of 
the  Fallopian  tubes,  and  sweeping  round  the  outside  of  the  pelvis, 
pass  out  through  the  inguinal  rings  into  the  labia  majora.  These 
ligaments,  as  well  as  all  the  others,  can  be  seen  by  looking  down 
upon  the  pelvic  organs  in  situ.  The  uterus  is  seen  in  the  middle 
of  the  pelvis,  and  extending  across  on  either  side  of  it  are  the  two 
broad  ligaments  made  up  of  the  two  folds  of  peritonreum,  which 
unite  after  covering  the  uterus.     Running  backward  from  the  uterus 


288 


DISEASES   OF  WOMEN. 


to  the  sacrum  are  those  peritoneal  folds  known  as  the  utero-sacral 
ligaments.     Between  the  uterus  and  the  bladder,  on  the  sides  of  the 

latter,  the  folds  of 
peritonaeum  form 
the  utero-vesical 
ligaments.  These 
ligaments  are  so 
called  not  because 
they  are  composed 
of  ligamentous  tis- 
sue, but  rather  be- 
cause tliey  perform 
a  function  similar 
to  that  of  liga- 
ments. With  the 
exception  of  the 
round  ligaments 
which  are  com- 
posed of  muscular 
tissue  covered  with 
peritonfeum,  the 
others  are  made  up 
of  double  folds  of 
peritonaeum  con- 
taining between 
these  folds  areolar 
tissue  and  some  fibers  of  the  pelvic  fascia.  An  idea  of  the  position 
of  these  ligaments  and  their  relations  to  the  uterus  may  be  obtained 
from  Fig.  136. 

I  have  noticed  that,  in  the  dissecting-room,  gentlemen  are  not 
able  at  all  times  to  find  the  utero-sacral  and  utero-vesical  ligaments ; 
the  broad  and  round  ligaments  they  easily  note.  The  others  can  be 
brought  into  view  in  the  following  manner:  If  the  uterus  be  drawn 
well  forward  by  a  tenaculum,  two  tense  bands  will  be  seen,  the  utero- 
sacral  ligaments,  extending  from  the  side  of  the  uterus  back  to  the 
sacrum,  and  as  they  are  thus  raised  up  a  pouch  of  peritonaeum  ap- 
pears between  them.  This  is  the  sac  of  Douglas.  By  reversing  this 
manipulation,  and  drawing  the  uterus  backward,  the  utero-vesical 
ligaments  will  be  seen  running  forward  on  either  side  of  the  bladder. 
The  utero-vesical  ligaments,  in  addition  to  their  attachments  to 
the  uterus  and  bony  walls  of  the  pelvis,  are  also  connected  indirect- 
ly to  the  anterior  vaginal  wall  by  intervening  areolar  tissue.     The 


Fig.  137. — Section  through  tlie  right  broad  ligament  showing 
its  relation  to  the  uterus,  tube,  ovary,  round  ligament, 
and  the  vessels  in  its  base. 


DISLOCATIONS  OP   THE   UTERUS. 


289 


utero-sacral  are  connected  in  the  same  indirect  way  with  the  upper 
portion  of  the  posteiior  va(:;inal  wall,  and  also  to  the  rectum,  on  tlie 
left  side  at  least.  At  the  junction  of  the  supra-vaginal  jjortion  of  the 
cervix  and  body  of  the  uterus  all  the  ligaments,  except  the  round 
ones,  are  attached.  Here  also  the  anterior  and  posterior  vaginal  wall 
and  a  portion  of  the  bladder  join  these  other  structures.  The  union 
of  these  structures  at  this  point  is  not  direct,  but  is  through  the  in- 
tervention of  areolar  tissue  which  is  found  in  considerable  quantity 
in  this  reo-ion.  From  this  it  will  be  seen  that  these  lio-aments  are 
continuous  from  side  to  side,  and  also  from  befoi'e  backward. 

The  chief  function  of  these  ligaments,  aided  by  the  anterior 
vaginal  wall,  is  to  keep  the  uterus  and  bladder  in  position.  This 
is  clearly  evident  from 
the  mechanical  princi- 
ple apparent  in  the  an- 
atomical arrangement 
of  the  parts  in  ques- 
tion, and  from  the 
fact  that  the  uterus 
remains  in  place  for 
a  considerable  time 
when  the  pelvic  floor 
is  defective,  and  the 
abdominal  pressure 
more  marked  than  nor- 
mal. 

In  short,  many 
cases  have  been  seen 
clinically  in  which  all 
the  other  means  that  Fig.  188 — Section  of  pelvis,with  the  antero-posterior  slings 
<>nnld  nossiblvcontrib-  "^  ^he  uterus;  behind,  the  utero-sacral  ligaments;  in 
COUia  pOSSlDiy  COniriO         ^^^^^^  ^^^  anterior  vaginal  wall  (after  a  frozen  section). 

ute  to  supporting  the 

uterus  were  removed  by  disease  and  injuries,  and  yet  the  uterus  was 
maintained  in  position  under  ordinary  circumstances.  The  most 
rational  idea  of  the  means  and  ways  by  which  the  uterus  is  main- 
tained in  the  pelvis  I  obtained  from  the  following  statement  by  Dr. 
Frank  P.  Foster.  Speaking  of  the  supports  of  the  uterus,  he  says : 
"  Ordinarily,  they  consist  wholly  of  the  anterior  wall  of  the  vagina 
in  front,  and  the  utero-sacral  ligaments  behind,  which  together  con- 
stitute what  may  be  called  a  beam  traversing  the  pelvis  antero- 
posteriorly  on  wdiich  the  uterus  rests,  being  interposed  between 
them,  firmly  attached  to  the  one  anteriorly  and  to  the  other  pos- 
20 


290  DISEASES   OF   WOMEN. 

teriorlj,  making  them,  so  far  as  mechanical  effect  is  concerned,  one 
structure.''  Tliis  is  a  clear  and  comprehensive  statement  of  the  prin- 
ciples upon  which  the  ntero-sacral  ligaments  and  the  anterior  vaginal 
wall  act  in  supporting  tlie  uterus.     I  would  go  one  step  further  than 


Fin.  1S9. — Diagram  of  the  uterus  slung  between  the  broad  ligaments  in  the  true  pelvis. 
The  round  ligament,  tube,  and  ovary  are  shown  on  one  side  only. 

Dr.  Foster,  however,  and  claim  a  like  function  for  the  other  uterine 
ligaments.  The  hroad  ligaments,  firmly  attached  to  the  bony  walls 
of  the  pelvis,  and  holding  the  uterus  in  their  folds,  make  a  continu- 
ous structure  extending  across  the  pelvis  in  its  transverse  diameter. 

These  structures,  taken  together,  act  like  '^  beams  "  or  (to  be  more 
mechani{uilly  accurate)  cables  of  a  suspension  bridge,  which  support 
to  a  large  extent  the  uterus  in  its  center.  The  utero-vesical  liga- 
ments also  su])plement  the  anterior  vaginal  wall  as  a  sup]')()rting 
medium.  According  to  this  view  of  the  subject,  the  chief  supports 
of  the  uterus  are  the  anterior  vaginal  wall,  utero-sacral,  vesico-uterine, 
and  I)road  ligaments. 

Fig.  138  shows  a  section  of  the  ])clvis  with  these  ligaments  and 
the  anterior  vaginal  wall  with  the  uterus  resting  upon  them. 

Fig.  139  shows  a  ti'ansverse  section  of  the  ])clvis  just  in  front  of 
the  uterus  and  broad  ligaments,  and  represents  these  structures  and 
the  uianner  in  which  they  support  the  uterus. 

A  similar  func-tion  may  be  claimed  for  the  round  ligaments,  at 
least  so  far  as  their  effect  in  preventing  the  backward  displacement 


DISLOCATIONS   OP  THE   UTERUS. 


291 


of  the  uterus.  Some  have  chiiuied  that  the  round  ligaments  have 
but  Httle  supportini^  power  to  sustain  the  uterus  in  place,  while 
otliers  give  it  much  credit  in  this  direction.  Those  who  believe  in 
Alexander's  operation  of  shortening  the  round  ligaments  for  the 
relief  of  retroversion  of  the  uterus  certainly  claim  great  supporting- 
power  for  these  ligaments,  and  with  good  reason,  I  think. 

Finally,  I  may  add,  that  I  believe  that  the  ligaments,  the  vagina, 
and  the  other  pelvic  organs  all  aid  in  keeping  the  uterus  in  position, 
and  are  sufficient  to  do  so  under  ordinary  circumstances.  Still,  when 
extraordinary  strain  is  brought  to  bear  upon  the  pelvic  organs,  the 
pelvic  floor  supplements  these  supporting  structures.  Moreover,  the 
relation  of  the  trunk  to  the  pelvis 
lias  much  to  do,  if  not  in  keeping 
the  pelvic  organs  in  place,  certainly 
in  freeing  them  from  pressure  from 
ahove. 

The  pelvis  is  so  placed  that,  in 
the  erect  posture,  its  cavity  is  be- 
hind rather  than  beneath  the  abdo- 
men, and  the  abdominal  muscles 
partially  divide  the  greater  cavity 
from  the  lesser.  This  is  shown  in 
Fig.  140,  where  the  arrow  indicates 
the  direction  of  the  force  trans- 
mitted to  the  pelvis  through  pres- 
sure from  above. 

There  is  very  little  direct  ab- 
dominal pressure  upon  the  pelvic 
organs  in  the  erect  posture.  The 
axis  of  the  pelvis  is  backward  and 
downward,  while  that  of  the  abdo- 
men is  perpendicular,  so  that  the  pressure  is  indirect  from  above. 

Some  claim  that  a  suction  power  is  exerted  upon  the  pelvic  con- 
tents by  the  diaphragm.  It  is  said  to  act  like  a  piston  in  the  cylinder 
of  a  pump.  There  is  reason  to  believe  there  is  something  in  this  ex- 
planation from  the  fact  that,  on  examination  through  a  Sims's  specu- 
lum, the  uterus  is  seen  to  rise  and  fall  with  respiration.  This  motion 
is  to  a  large  extent  arrested  when  the  patient  is  in  the  erect  posture. 

If  it  is  a  fact,  as  it  apjiears  to  be,  that  the  abdominal  organs  are 
fixed  by  suspension  in  their  normal  position,  and  that  in  their  descent 
during  this  limited  motion  the  pressure  upon  the  pelvic  organs  is 
indirect,  then  this  relationship  contributes  to  maintain  the  position  of 


Fig.  140. — The  normal  inclination  of  the 
pelvis  and  the  transmission  of  force 
from  above. 


292  DISEASES   OF   WOMEN. 

the  pelvic  organs  as  surely  as  if  there  were  some  traction  or  suction 
action  of  tlie  diaphragm  tending  to  draw  these  organs  upward. 

In  regard  to  the  pelvic  floor  and  its  i-elations  to  the  displacements 
of  the  uterus,  that  subject  has  been  fully  discussed  under  the  head 
of  injuries  of  the  pelvic  floor.  It  is  only  necessary  to  repeat  my 
belief  already  expressed  to  the  effect  that,  while  the  pelvic  floor  does 
not  directly  support  the  uterus,  it  indirectly  aids  in  doing  so,  and  if 
it  is  lost  from  injury  prolapsus  of  the  pelvic  organs  follows  as  a  rule. 


DISPLACEMENTS    OF    THE    UTERUS. 

There  are  a  great  many  forms  of  displacement  of  the  uterus,  if 
every  change  of  position  of  that  organ  be  taken  into  account,  but  of 
those  that  occur  as  ])rimary  affections  there  are  only  two  that  are 
often  seen,  and  one  that  is  very  rare.  These  are  downward,  back- 
ward, and  forward — that  is,  prolapsus,  retroversion,  and  antever- 
sion. 

Prolapsus  and  retroversion  are  really  the  only  forms  of  displace- 
ment which  practically  claim  attention  in  this  connection.  These 
the  gynecologist  is  called  upon  to  treat  daily  as  primary  affections. 
Occasionally,  a  case  of  anteversion  may  be  seen  which  apparently  is 
not  caused  by  some  other  affection  more  important  than  the  conse- 
quent displacement,  but  this  is  exceedingly  rare.  Again  the  uterus 
may  be  anteverted  to  a  considerable  extent  without  causing  the 
slightest  trouble.  This  form  of  displacement  (quite  a  rare  one)  is 
generally  produced  as  a  consequence  of  some  other  disease,  either  of 
the  uterus  itself  or  the  organs  and  tissues  around  it,  or  else  when  it 
does  occur  it  gives  no  trouble  ;  and,  as  a  rule,  very  little  can  be  done 
to  relieve  it  by  the  ordinary  methods  of  treating  uncomplicated  dis- 
placements. Taking  all  this  into  account,  it  is  evident  that  the 
downward  and  backward  displacements  alone  demand  special  atten- 
tion, either  in  practice  or  in  the  discussion  of  the  subject. 

The  other  forms  of  displacement  of  the  uterus,  described  in  text- 
books, are  the  right  and  left  lateral  anteversions  and  retroversions. 
These  displacements  are  always  due  either  to  some  lesion  of  develop- 
ment or  to  some  ]:)revious  affection,  the  products  of  which  either 
push  or  pull  the  uterus  out  of  place.  There  is  also  a  retrocessioK 
of  the  uterus  and  an  antecession,  which  are  not  described  in  books. 
Perha])s  better  names  for  these  would  be  transposition  backward  or 
forward.  In  these  dislocations  the  uterus  is  found  either  behind  or 
in  front  of  the  axis  of  the  pelvic  cavity,  or  superior  strait.  These, 
like  the  lateral  dislocations,  are  secondary  to  some  abnormal  state 


DISLOCATIONS   OF   THE   UTERUS. 


293 


which  caused  them,  and  hence  they  are  to  he  looked  upon  as  signs 
and  consequences  of  tlie  primary  disease. 

By  adopting  this  classification  it  simplifies  the  subject  very 
much,  and  leaves  one  free  to  give  attention  to  the  downward  and 
backward  dislocations  and  their  pathology,  diagnosis,  cansation,  and 
treatment.  Again,  the  two  forms  of  displacement  in  question  are 
the  only  conditions  of  malposition  that  can  be  directly  treated  with 
favorable  results.  In  the  other  forms,  such  as  lateral  versions,  treat- 
ment must  be  employed  to  remove  the  morbid  states  which  push  or 
pull  the  uterus  out  of  place,  and  therefore,  the  discussion  of  such 
displacements  should  be  confined  to  the  diseases  which  cause  them. 


PROLAPSUS    OF    THE    UTERUS. 

This  is  a  downward  displacement  of  the  uterus  commonly  called 
falling.  It  is  of  necessity  always  associated  with.  disjDlacement  of  the 
other  pelvic  organs  and 
tissues,  to  a  greater  or  less 
extent,  according  to  the 
degree  of  descent  of  the 
uterus. 

There  are  several  de- 
grees of  prolapsus  uteri 
which  have  been  various 
ly  described.  While  au- 
thors designate  the  most 
important  stages  of  de- 
scent by  degrees,  it  should 
be  understood  that  practi- 
cally there  is  no  line  of 
demarkation  between  the 
degrees.  According  to 
this  arrangement,  when 
the  uterus  sinks  so  that 
the  cervix  rests  entirely 
on  the  pelvic  fioor,  it  is 
named  prolapsus  of  the  first  degree  ;  when  the  uterine  axis  has  be- 
come vertical  or  coincides  with  the  axis  of  the  outlet,  the  cervix  ap- 
pearing at  the  vulva,  the  second  degree  is  present ;  while  in  the 
third  degree  the  organ  is  partly  or  wholly  outside  the  introitus. 
Fig.  l-il  shows  the  three  degrees,  and  may  convey  a  clearer  idea 
than  further  description. 


Fig.  141. — The  three  degrees  of  prolapsus.   The  upper 
outline  is  a  little  above  the  normal  position. 


294  DISEASES  OF  WOMEK 

By  some  authorities  all  the  degrees  of  prolapsus  in  which  the 
uterus  still  remains  within  the  vulva  are  termed  incomplete,  while 
those  in  which  it  protrudes  partially  or  completely  beyond  the  vulva 
are  called  complete. 

This  latter  arrangement  of  the  subject  is  perhaps  as  easily  com- 
j)rehended  and  as  useful  in  practice  as  any  other.  The  complete 
degree  is  often  spoken  of  as  procidentia. 

Pathology. — Prolapsus  of  the  uterus  takes  place  slowly,  as  a  rule. 
Sudden  prolapsus  may  possibly  occur,  but  it  nuist  be  a  rare  thing,  ex- 
cept in  the  first  degree.  In  the  few  cases  that  I  have  had  an  oppor- 
tunity of  watching  from  beginning  to  completion,  the  displacement 
has  been  gradual.  At  first  the  uterus  descended  to  the  first  degree 
of  prolapsus,  and  then  to  the  second,  and  finally  to  the  third  or  com- 
plete stage.  The  time  occupied  in  making  the  complete  descent 
varies  from  months  to  years.  The  changes  which  take  place  in  the 
supports  of  the  uterus  and  the  other  pelvic  organs  during  the  pro- 
gressive development  of  the  prolapsus  are  usually  the  same  in  all 
cases  with  few  exceptions,  but  the  order  in  which  they  a]>pear  differs 
according  to  the  cause  of  the  descent.  This  again  depends  upon  the 
point  in  the  structures  at  wliicli  the  lesions  l)egin  to  develop. 
There  are  three  methods  of  development  of  prolapsus.  In  the  first, 
the  uterus  begins  to  descend  because  it  is  too  heavy  and  makes  too 
great  demands  upon  its  innnediate  supports,  or  else  these  supports 
become  defective  from  pathological  changes.  This  is  a  descent  of 
the  uterus  from  loss  of  direct  support.  The  second  order  of  descent 
is  by  loss  of  the  pelvic  floor,  which  permits  the  vagina,  bladder,  and 
part  of  the  rectum  to  descend,  and  then  the  uterus  follows.  The 
third  in  order  is  made  up  of  the  two  others,  the  first  and  the  second, 
all  the  conditions  mentioned  in  those  being  operative  at  the  same 
time. 

The  changes  in  the  supports  are  elongation  from  imperfect  in- 
volution after  parturition,  or  stretching  pi'oduced  by  enlargement  of 
the  uterus,  or  pressure  on  it  from  above  by  long  standing,  stoo])ing, 
or  lifting.  In  the  former  condition  the  supports  are  too  long ;  in 
the  latter  they  are  attenuated  as  M'ell  as  elongated.  In  l)otli  states 
the  upper  portion  of  the  vagina  is  distended  and  the  bladder  slightly 
prolapsed  or  drawn  backward.  There  is  also,  in  some  cases,  loss  of 
the  areolar  tissue,  and  the  pelvic  fascia  has  lost  its  strength  of  fiber. 
This  traction  upon  the  rectum,  bladder,  and  the  blood-vessels  is  pre- 
sumed to  interrupt  the  return  circulation.  Whether  that  is  a  fact  as 
regards  the  causation  or  not,  there  is  usually  a  ])assive  hypera'mia 
of  the  parts  in  these  dis])lacenienis.     These  changes  of  the  positior 


DISLOCATIONS   OF   THE   UTERUS.  295 

and  relations  of  tliese  parts  are  gradually  developed.  In  case  the 
prolapsus  proceeds  to  the  third  degree,  the  pelvic  lioor  gives  way 
under  the  influence  of  the  continued  pressure.  The  perineal  mus- 
cles become  overdistended  and  the  vulva  enlarged,  until  the  uterus 
is  permitted  to  protrude  without  resistance. 

In  the  second  order  of  the  development  of  prolapsus — that  is, 
where  the  loss  of  the  pelvic  floor  is  the  starting-point  of  the  mal- 
position, the  first  lesions  appear  in  the  vagina.  The  walls  of  the 
vagina  at  the  introitus  begin  to  protrude  and  their  descent  is  gener- 
ally attended  with  increase  of  tissue.  Usually  both  w^alls  prolapse 
together,  but  in  many  cases  one  or  the  other  takes  precedence.  As 
the  prolapsus  progresses  the  bladder  and  anterior  wall  of  the  rectum 
descend,  producing  rectocele  and  cystocele.  In  due  time  the  uterus 
follows  with  all  the  changes  in  its  supports  already  described  above. 
There  are  cases  in  which  the  prolapsus  begins  at  the  lower  part  of 
the  vagina,  while  there  is  no  apparent  injury  of  the  pelvic  floor. 
This  has  been  accounted  for  by  imperfect  involution  of  the  vagina 
after  child-bearing.  The  large,  heavy,  and  lax  walls  of  the  vagina 
make  undue  pressure  upon  the  pelvic  floor  and  it  gives  way  before 
them.  A  similar  state  of  things  occurs,  so  far  as  appearances  are 
concerned,  where  there  has  been  subcutaneous  laceration  of  the  mus- 
cles of  the  pelvic  floor  which  impairs  its  function. 

Prolapsus  of  long  standing  changes  the  sti-uctnre  of  all  the 
tissues.  Atrophy  of  the  muscular  tissue  of  the  vagina  and  pelvic 
floor  occurs,  and  the  ligaments  of  the  uterus  lose  their  character- 
istics so  that  they  can  not  he  restored  to  their  original  state  by  any 
means. 

There  is  a  prolapsus  which  occurs  as  the  result  of  degeneration 
of  the  supports  of  the  uterus.  It  occurs  in  feeble  old  women  in 
whom  general  nutrition  is  greatly  impaired.  The  perinaeum  and 
vagina  lose  their  elasticity,  the  adipose  and  areolar  tissue  disappear, 
and  the  vaginal  walls,  bladder,  and  atrophied  uterus  descend.  Such 
patients  are  also  subject  to  prolapsus  of  the  rectum  and  sometimes 
prolapsus  of  the  mucous  membrane  of  the  urethra.  I  have  called 
this  senile  prolapsus  to  distinguish  it  from  the  ordinary  descent  of 
the  uterus  which  usually  occurs  in  middle  life.  I  believe  it  to  be 
due  to  the  general  atrophy  of  the  pelvic  viscera  because  of  the  time 
of  life  when  it  occurs,  and  the  fact  that  I  have  seen  it  in  those  who 
have  not  borne  children.  The  first  case  that  I  carefully  studied  was 
in  an  old  maiden  of  seventy  years  of  age. 

Syinptomatology. — The  natural  history  of  prola])sus  uteri  as 
manifested  by  symptoms  and  physical  signs,  differs  to  some  extent 


296  DISEASES   OF  WOMEN. 

in  different  cases,  though  the  pathological  conditions  appear  to  be 
the  same  in  all.  The  suffering  caused  varies  according  to  the  general 
health  and  nervous  sensitiveness  of  the  subjects  affected.  What  is 
more  strange  still,  is  the  fact  that  incomplete  prolapsus  often  causes 
more  suffering  than  the  more  advanced  stages.  It  is  not  an  uncom- 
mon thing  to  see  a  patient  with  complete  prolapsus  of  the  uterus 
who  complains  less  than  another  in  whom  the  uterus  is  still  within 
the  pelvis. 

The  symptoms  indicative  of  prolapsus  uteri  maybe  classed  under 
two  heads  :  First,  the  derangement  of  the  functions  of  the  other 
pelvic  organs,  and,  second,  the  disordered  nutrition  of  the  tissues  of 
the  pelvic  viscera  generally.  The  dragging  of  the  uterus  upon  the 
bladder  and  rectum,  and  the  abnormal  pressure  cause  irritation, 
which  gives  rise  to  rectal  and  vesical  tenesmus.  The  constant  desire 
to  evacuate  the  rectum  and  bladder,  is  often  very  distressing.  These 
symptoms  are  greatly  aggravated  by  walking,  lifting,  coughing,  and 
especially  by  standing,  and  they  are  all  relieved  in  a  very  marked 
degree,  often  completely  so,  by  lying  down.  This  difference  in 
the  feelings  of  the  patient,  when  in  the  erect  or  recumbent  posi- 
tion, is  a  diagnostic  point  of  very  great  value.  The  recumbent  po- 
sition generally  gives  relief  in  the  majority  of  the  diseases  of  the 
pelvic  organs,  but  not  so  markedly  as  in  displacements  of  the  uterus. 

The  malnutrition  produced  by  irritation  and  deranged  circula- 
tion leads  in  time  to  inflammatory  affections  of  the  uterus  and  other 
pelvic  organs.  This  is  not  an  acute  inflammation  which  can  be  seen, 
but  a  hypercemia  accompanied  by  tissue  changes  such  as  areolar  hy- 
perplasia and  catarrhal  states  of  the  mucous  membrane.  It  is  prob- 
able that  the  endometritis  so  common  in  prolapsus  uteri  may,  in 
many  cases,  precede  the  displacement,  but  the  displacement  certainly 
tends  to  keep  it  up.  The  symptoms  of  these  affections  need  not  be 
given  here. 

The  symptoms  manifested  by  the  general  system  in  this  affec- 
tion are  not  marked  nor  s])ecial.  Beyond  the  backache  and  deranged 
digestion  which  often  accompany  prolapsus,  and  the  depression  which 
comes  from  a  consciousness  of  having  some  chronic  ailment  which 
impairs  locomotion  and  general  usefulness,  there  is  not  nnich  that 
need  be  mentioned. 

Physical  Signs. — In  prolapsus  in  the  first  degree,  the  uterus 
presses  the  posterior  vaginal  wall  downward,  and  encroaches  upon 
the  rectum  to  some  extent,  at  the  same  time  it  inclines  backward. 
In  some  cases  the  cervix  rests  so  heavily  upon  the  floor  of  the  pelvis 
that  it  becomes  flattened.     This  is  easily  detected  by  digital  exam- 


DISLOCATIONS   OF   THE   UTERUS. 


297 


ination,  which  reveals  the  descent  of  the  utei-us.  The  space  from 
tlie  piibes  to  the  anterior  wall  of  the  body  and  fundus  uteri  is  en- 
larged and  remains  so  when  the  bladder  is  empty.  The  u])per  por- 
tion of  the  vagina  is  often  relaxed  and  wider  than  normal. 


cervix 
Fig.  142. — Prolapsus  uteri  with  cystocele. 

In  the  second  degree  of  prolapsus,  the  os  points  toward  the  os- 
tium vaginse,  and  is  at  or  near  the  vaginal  outlet.  The  fmidus  uteri 
lies  back  toward  the  sacrum  but  not  usually  so  far  as  in  marked  re- 
troversion. In  complete  prolapsus  the  uterus  protrudes  from  tlie 
vagina,  and  can  be  easily  recognized  by  inspection.  In  this  third 
degree  of  prolapsus,  the  bladder  and  anterior  wall  of  the  rectum 
are  usually  drawn  with  the  uterus,  and  in  extreme  cases,  the  urethi*a 
also.  The  extent  to  which  these  organs  accompany  the  uterus  in  its 
descent  varies  considerably.  This  may  be  determined  by  passing  a 
sound  into  the  bladder  and  ascertaining  its  direction,  and  the  same 
means  will  show  the  extent  of  the  prolapsus  of  the  rectal  walls. 


298 


DISEASES   OF   WOMEN. 


Diagnosis. — The  affections  which  simulate  prolapsus  uteri  are 
h}q)ertrophic  elongation  of  the  cervix,  librous  polypus,  and  inver- 
sion. A  polypus  and  an  inverted  uterus  may  be  excluded  by  the 
absence  of  the  os  and  cervical  canal,  and  by  the  fact  that  they  are 
covered  with  the  mucous  membrane  of  the  uterus,  while  the  pro- 
lapsed uterus  is  covered  with  the  mucous  membrane  of  the  vagina. 

The  elongation  of  the  neck  of  the  uterus  can  be  detected  by 
passing  the  sound,  and  at  the  same  time  pushing  the  uteras  up  into 
the  pelvis,  until  the  fundus  can  be  detected  by  palpation  of  the  ab- 
domen ;  that  is,  by  making  the  bimanual  examination.  The  fact 
that  this  hypertrophy  of  the  cervix  occurs,  as  a  rule,  in  those  who 
have  not  borne  children,  will  also  aid  in  the  diagnosis.  There  are 
cases  of  prolapsus  in  which  the  uterus  is  greatly  relaxed,  and  be- 
comes elongated,  so  that  the  sound,  when  passed  to  the  fundus, 
shows  a  great  increase  in  its  long  diameter.  By  replacing  the  uterus 
it  becomes  shortened  very  considerably ;  the  shortening,  I  presume, 
is  due  to  contraction  or  condensation  of  the  tissues.  This  has  been 
described  by  Emmet  as  a  process  of  telescoping,  but  I  think  the 

term  is  ill  chosen.     One  can  not 
"^Z  conceive    of    portions    of    the 

uterus  being  pushed  into  each 
other  like  sections  of  a  tele- 
scope. 

In  the  physical  examination 
of  prolapsus,  care  should  be 
taken  to  discover  any  compli- 
cations which  may  exist,  such 
as  neoplasms  of  the  uterus, 
which  greatly  increase  its  size, 
abdominal  tumors  which  crowd 
••,  ;  .. '      the  uterus  downward,  and  atro- 

l\    \\  \        pliy  of  the  muscles  of  the  pel- 

i    W  /         vie  floor  and  vagina. 

I    \  \  I  Causation. — The    fine    ad- 

4    '■''         /  justment  of  the  uterus  and  the 

means  which  keep  that  organ  in 
its  place,  and  yet  permit  con- 
siderable motion,  are  such  that 
any  increase  of  weight  of  the 
one,  or  loss  of  strength  of  the 
other  will  cause  displacement.  The  formation  of  the  pelvis,  and  its 
position  in  relation  to  the  vertebral  column  :  the  character  of  the 


'-...> .■•■■■' 

Fig.  148. — The  shallow  pelvis  with  lessened 
inclination  of  brim.  The  direct  action  of 
tlie  pressure  from  above  is  shown  by  the 
arrows. 


DISLOCATIONS   OF   THE   UTERUS. 


299 


fiber  of  the  uterine  supjiorts,  the  quantity  and  consistence  of  the 
areolar  and  adipose  tissue ;  one's  habits  in  regard  to  clothing,  posi- 
tion in  standing  and  sitting,  if  main- 
tained unduly  long,  character  of  oc- 
cupation, strength  or  weakness  of 
general  organization  ;  and  the  acci- 
dents and  injuries  incident  to  child- 
bearing,  all  have  certain  influences  in 
causing  dislocations  of  the  uterus. 

A  shallow  and  wide  pelvis  (Fig. 
143)  which  is  more  than  sufficient 
for  the  accommodation  of  its  con- 
tents, while  it  is  favorable  to  easy 
parturitions,  predisposes  to  descent 
of  the  uterus.  Again,  if  the  pelvis 
is  tilted  forward,  so  that  it  is  brought 
more  immediately  under  the  axis  of 
the  abdomen  (Fig.  143)  the  pelvic 
organs  are  constantly  under  greater 
pressure  than  normal,  and  prolapsus 
and  retroversion  are  likely  to  occur. 
These  facts  regarding  the  form  and 

position  of  the  pelvis  are  factors  of  great  importance  in  the  problem 
of  uterine  displacement,  and  deserve  more  attention  than  has  been 
given  to  them. 

The  habit  of  walking  erect  has  the  effect  of  maintaining  this 
favorable  relation  of  the  abdomen  and  pelvis,  while  stooping  distm'bs 
this  harmony  of  relative  positions.  In  this,  both  in  regard  to  forma- 
tion and  habit  of  standing  and  walking,  there  is  the  greatest  diversity 
among  women.  The  tissues  of  the  uterine  supports,  when  defective 
in  quantity  or  quality,  are  incapable  of  performing  their  functions. 
These  effects  may  be  the  result  of  imperfect  development  such  as 
occurs  in  those  of  sedentary  habits  in  youth,  or  they  may  come  from 
debilitating  diseases.  In  the  one  case  they  have  never  been  well  de- 
veloped, and  in  the  other  they  have  become  atrophied.  Standing 
and  walking  to  an  extent  that  is  fatiguing,  bring  undue  strain  upon 
the  pelvic  organs,  and  if  persisted  in,  will  in  time  produce  prolapsus. 
Active  exercise,  with  liberal  periods  of  rest,  will  tend  to  strengthen 
the  uterine  supports,  but  fatigue  will  overcome  their  power  of  re- 
sistance. Stooping  forward  while  in  the  sitting  position  has  a  two- 
fold injurious  influence — it  interrupts  the  return-circulation  in  the 
pelvis  and  impairs  the  nutrition  of  the  organs  and  brings  increased 


Fig.  144. — Increased  inclination  of  in- 
let.   Pelvic  organs  escape  pressure. 


300  DISEASES   OF  WOMEN. 

downward  pressure  to  bear  on  them.  The  position  of  the  girl  at 
tlie  sewing-machine  and  that  of  the  lady  of  leisure,  bent  over  in  her 
easj-cliair  while  reading  a  novel,  are  alike  hurtful,  but  worst  of  all, 
the  school-girl,  bending  over  her  desk  all  daj,  while  her  body  is,  or 
should  be  developing,  suffers  the  most  injury.  Among  the  errors 
in  the  use  of  clothing,  the  abuse  of  corsets  does  the  most  harm.  I 
would  not  be  understood  as  condemning  corsets.  Long  use  has  ren- 
dered that  kind  of  support  necessary  to  highly  civilized  women,  but 
tight-lacing  forces  the  abdominal  viscera  out  of  place  and  in  time 
displaces  the  j)elvic  organs. 

Heavy  lifting,  if  persisted  in,  is  a  cause  of  displacement.  This 
is  noticed  among  the  poor  who  do  heavy  work.  The  women  of  In- 
dia, who  were  at  one  time  supposed  to  bear  children  with  ease  and 
impunity,  and  to  suffer  less  from  uterine  affections  than  our  Ameri- 
can women,  are  very  subject  to  complete  prolapsus  uteri,  caused  no 
doubt  from  their  want  of  cai"e  after  confinement  and  in  carrying 
heavy  burdens.  General  weakness,  induced  by  exhausting  diseases 
and  extreme  old  age,  affects  the  pelvic  organs  very  decidedly.  This, 
no  doubt,  is  the  cause  of  prolapsus  uteri  in  women  with  consump- 
tion and  in  the  veiy  aged. 

The  most  important,  certainly  the  most  frequent,  causes  of  uter- 
ine displacement  are  the  injuries  and  improper  management  incident 
to  child-bearing.  The  condition  of  the  uterine  supports  after  partu- 
rition is  that  they  are  all  greatly  enlarged  through  the  growth  of 
gestation,  and,  while  they  are  competent  to  maintain  the  large  uterus 
which  rests  in  the  abdominal  cavity,  they  must  undergo  involution 
in  conjunction  with  the  diminution  of  the  uterus.  If  this  involu- 
tion fails  in  the  uterine  ligaments  and  vagina  while  it  goes  on  in  the 
uterus  the  supports  fail,  because  they  are  too  long  and  relaxed.  Im- 
perfect involution,  not  only  of  the  uterus  but  of  all  the  other  tissues 
and  organs  of  the  pelvis,  is  seen  to  give  rise  to  displacement.  This 
imperfect  involution  may  be  due  to  post-partum  inflammation  or  to 
the  patient  resuming  the  active  duties  of  life  before  involution  is 
completed.  In  regard  to  the  injuries  of  the  pelvic  floor  and  their 
effect  on  the  position  of  the  uterus  the  reader  is  referred  to  the 
chapter  on  that  subject. 

Finally,  enlargement  of  the  uterus,  whether  from  imperfect  in- 
volution, inflaiimiation,  or  the  presence  of  neoplasms,  will  cause 
prolapsus.  This  will  occur  although  all  the  supports  may  be  nor- 
mal ;  the  balance  between  the  supports  and  the  organs  to  be  sup- 
ported being  disturbed  by  the  increased  weight  of  the  uterus,  de- 
scent will  occur. 


DISLOCATIONS   OF   THE   UTERUS.  301 

It  should  also  be  borne  in  mind  that  the  abnormally  large  uterus 
will  prolapse  in  spite  of  the  normal  supports,  while,  on  the  other 
hand,  defective  suj^poi-ts  which  permit  a  normal  uterus  to  descend 
will  give  rise  to  enlargement  of  the  uterus  hj  congestion,  swelling, 
and,  finally,  hyperplasia,  and  by  this  increase  of  weight  will  incline 
it  to  remain  displaced. 


TREATMENT   OF  PROLAPSUS  UTERI. 

There  are  four  important  objects  to  be  attained  in  the  treatment 
of  prolapsus  uteri :  to  restore  the  displaced  organ,  to  keep  it  in  place, 
to  restore  the  supports  of  the  uterus,  and  to  remove  complications 
and  accompanying  affections  if  any  such  exist. 

The  restoration  of  the  uterus  to  its  proper  place  is  performed  as 
follows  :  The  patient  is  placed  in  Sims's  position,  and,  if  the  pro- 
lapsus is  comj^lete,  the  uterus  is  grasped  in  the  lingers,  and,  while 
compression  is  made,  it  is  pushed  upward  in  the  axis  of  the  pelvic 
cavity.  By  these  means  the  displacement  is  reduced  from  the  third 
degree  to  the  second ;  then  the  perinaeum  should  be  retracted  with 
Sims's  speculum,  and  with  two  sponges  in  holders  the  uterus  should 
be  raised  to  its  normal  elevation.  Difficulty  in  accomphshing  this  is 
sometimes  caused  by  the  fundus  uteri  turning  backward  while  the 
upward  pressure  is  being  made,  so  that,  in  place  of  overcoming  the 
displacement,  the  prolapsus  is  changed  to  a  retroversion.  This  can 
be  guarded  against  by  making  the  pressure  mostly  on  the  posterior 
side  of  the  cervix.  Passing  the  sound  and  making  it  guide  the 
uterus  in  the  right  direction  while  upward  pressure  is  being  made  is 
another  way  of  managing  difficult  cases.  While  these  manijjulations 
are  being  made  the  patient  should  relax  the  abdominal  muscles  by 
avoiding  all  straining.  Many  patients  fail  to  obey  orders  in  this 
respect ;  they  continue  to  hold  the  breath,  and  strain  as  if  preparing 
to  resist  the  pain  of  some  injury  about  to  be  inflicted  upon  them,  I 
have  overcome  this  annoyance  by  causing  the  patient  to  take  long 
regular  respirations  while  being  treated.  In  rare  cases,  in  which 
much  difficulty  is  met  in  replacing  the  fallen  uterus,  the  patient 
should  be  placed  in  the  knee-chest  position,  and  then  the  chances  are 
that  the  uterus  will  slip  back  to  its  position  mthout  much  hel]?.  If 
any  aid  is  needed  it  can  be  given  by  the  sponges  in  holders,  or  what 
is  quite  as  good,  if  not  better,  in  manipulating  with  the  patient  in 
this  position,  is  to  use  one  or  two  fingers  in  place  of  the  sponges. 
With  a  very  limited  experience  and  a  knowledge  of  the  methods 
described  any  one  can  manage  this  portion  of  the  treatment.     To 


302  DISEASES  OF   WOMEN. 

keep  the  uterus  in  place  is  the  question  which  is  not  easily  settled. 
The  object  of  all  the  mechanical  means  which  may  be  employed  is, 
first,  to  keep  the  organ  in  position  and  thereby  give  relief;  at  the 
same  time,  through  the  agency  of  the  artificial  support  and  otlier 
means,  to  restore  the  natural  supports. 

If  the  prolapse  is  not  beyond  the  second  degree,  and  is  due  to 
relaxation  only  of  the  uterine  supports,  and  not  associated  with  any 
injury  that  destroys  the  integrity  of  the  pelvic  floor,  the  uterus  may 
be  retained  by  means  of  a  pessary  or  tampon  until  the  supports 
recover  their  original  strength.  In  connection  with  these  mechani- 
cal means,  rest  in  the  recumbent  position  is  one  of  the  most  im- 
portant factors  in  bringing  about  the  desired  result. 

The  material  used  for  the  tampon  should  be  absorbent  cotton, 
wool,  or  lint.  To  simply  keep  the  uterus  in  place  wool  is  no 
doubt  the  best.  It  is  soft  and  least  irritant  to  the  tissues.  When 
there  is  any  vaginitis  or  endometritis  causing  a  free  discharge,  ma- 
rine lint  does  better.  It  takes  up  the  discharge,  disinfects  it,  and 
prevents  decomposition.  This  it  does  better  than  either  cotton  or 
wool.  In  some  cases  lint  is  irritating  to  the  tissues  and  can  not  I)e 
long  continued.  Sometimes  I  have  used  wool  and  lint  alternately 
with  much  satisfaction. 

Since  the  introduction  of  antiseptic  material  for  dressings,  the 
tampon  has  been  far  more  useful  in  surgery.  In  the  past  when 
sponges,  not  well  prepared,  were  used,  they  could  be  retained  in 
place  but  a  few  hours  without  causing  decomposition.  Now  the 
marine  lint  or  l)orated  cotton  can  be  worn  twenty-four  or  forty-eight 
hours  without  being  offensive. 

•For  those  who  have  vaginitis  or  any  inflammation  of  the  uterus  I 
direct  that  the  tampon  be  applied  in  the  morning  after  having  used 
the  douche  of  hot  water,  plain  or  medicated.  At  night  tlie  tampon 
is  removed  and  the  douche  again  used  and  afterward  the  tampon  re- 
placed, if  the  uterus  will  not  stay  in  place  without  it,  but  omitting 
it  for  the  night  if  the  recumbent  position  will  overcome  the  tend- 
ency to  displacement.  When  there  is  no  inflammatory  complication 
the  tampon  may  be  left  in  place  two  days  and  a  night.  At  the  end 
of  the  second  day  it  should  be  removed  at  bed-time  and  replaced 
next  moniing,  the  douche  being  used  after  removal  and  before  intro- 
ducing it  again. 

Astringents  of  various  kinds  have  been  employed  with  the  tam- 
pon, the  cotton  being  saturated  with  the  solution  to  be  used,  or  tlie 
agent  may  l)e  employed  in  ])()wder.  The  latter  is  much  the  prefer- 
able way  wlien  the  milder  astringents  are  selected.     As  a  rule  I  pre- 


DISLOCATIONS   OF  THE  UTERUS.  303 

fer  the  borated  cotton  or  marine  lint  alone,  using  sucli  astringents  as 
may  bo  re(juirecl  in  tlie  douche. 

In  many  cases  there  is  some  loss  of  the  pelvic  floor  from  pre- 
vious injury.  This  structure  should  be  restored  as  soon  as  the  tis 
sues  are  in  a  condition  to  warrant  surgical  treatment.  As  a  rule,  in 
those  cases  oi  prolapsus  which  have  existed  for  some  time,  the  nu- 
trition of  the  tissues  is  impaired  and  needs  treatment  preparatory  to 
operating.  For  a  more  complete  discussion  of  this  subject  the 
reader  is  referred  to  the  chapter  on  injuries  of  the  pelvic  floor. 

Keeping  the  uterus  in  its  position  by  the  tampon  and  other 
means  of  support  has  the  effect  of  not  merely  relieving  the  prolapsus, 
but  also  of  giving  the  uterine  Ugaments  every  chance  to  regain  their 
nonnal  condition.  Artificial  support  is  palliative  and  curative  as 
well.  The  mechanical  supports  used  in  the  treatment  of  prolapsus 
include  a  variety  of  devices.  The  pessaries  used  are  of  two  kinds^ 
those  that  are  placed  in  the  vagina  and  are  held  in  position  by  the 
pelvic  floor,  and  those  that  are  held  in  place  by  being  attached  to  a 
strap  round  the  waist.  The  former  are  applicable  in  the  first  and 
second  degrees  of  prolapsus  while  the  pelvic  floor  remains  normal  or 
nearly  so.  The  latter  are  used  in  complete  prolapsus,  and  in  those 
cases  where  there  is  so  much  loss  of  the  pelvic  floor  that  it  will  not 
keep  the  pessary  in  position.  When  the  perinseum  is  sufficient  to 
support  the  vagina  and  the  prolapsus  is  limited  to  the  first  or  second 
degree,  the  instrument  known  as  Peaslee's  pessary  answers  very  well. 
It  is  a  simple  ring  made  of  whalebone  and  covered  with  soft  rub- 
ber. When  in  position  it  rests  upon  the  pelvic  floor.  It  should 
admit  the  cervix  without  making  pressure  upon  it,  and  should  fit 
the  upper  portion  of  the  vagina  without  distending  it  to  any  appre- 
ciable extent.  It  acts  by  carrying  the  upper  portion  of  the  vagina 
and  the  cervix  backward  into  the  normal  position,  and  at  the  same 
time  raises  the  uterus  to  a  very  slight  but  sufficient  extent.  If 
well  adapted  it  takes  off  the  pressure  from  the  lower  part  of  the 
vagina  and  permits  it  to  contract  and  regain  its  tonicity.  Fig.  142 
represents  prolapsus  in  the  second  degree.  Fig.  145  shows  the  pes- 
sary in  position  after  the  uterus  has  been  replaced. 

When  there  is  relaxation  of  the  pelvic  floor  due  to  the  prolapsus 
it  is  necessary  to  keep  the  patient  at  rest  much  of  the  time  during 
the  first  week  or  two  that  the  pessary  is  worn.  If  this  is  not  prac- 
ticable a  perineal  band  should  be  worn  to  support  the  pelvic  floor 
while  the  patient  is  exercising.  In  the  progress  of  the  treatment 
the  vagina  should  contract  when  the  uterus  is  supported  by  the 
pessary.    This,  in  time,  requires  that  a  smaller  instrument  should  be 


304 


DISEASES   OF   WOMEN. 


used.     The  rnle  is  that  the  smallest  instrument  should  be  employed 
that  will  keep  the  uterus  in  place.     If  too  large  a  pessary  is  used  it 


Uterus  replaced,  with  pessary  m  pusiiiuh 


will  keep  the  uterus  in  place,  but  will  overdistend  the  vagina  and 
weaken  the  supports  of  the  uterus  in  place  of  restoring  them. 

One  great  advantage  which  the  ring  pessary  has  is  in  being 
easily  introduced  or  withdrawn,  and  that  it  does  not  become  displaced 
except  to  settle  downward,  and  this  can  be  easily  corrected  by  tlie 
patient  assuming  the  knee-chest  position  from  time  to  time. 

When  tlie  uterus  inclines  to  retrovert  after  having  been  elevated, 
a  common  occurrence,  a  retroversion  pessary  will  act  better  than  the 
ring,  but  the  use  of  that  instrument  will  be  more  fully  discussed 
under  the  head  of  retroversion. 

Prolapsus  occurring  after  the  menopause  when  the  uterus  has 
undergone  final  involution,  may  bo  relieved  in  some  cases  by  the  old 
glass-globe  pessary.     It  certainly  is  the  best  instrument  that  I  have 


DISLOCATIONS  OF  THE   UTERUS.  305 

found  for  old  patients  having  prolapsus  of  the  vaginal  walls,  bladder, 
and  the  remains  of  the  atrophied  uterus,  if  the  pelvic  floor  remains 
sufficient  to  support  tlie  pessary.  It  simply  keeps  the  uterus  and 
bladder  up  in  the  pelvis  by  distending  the  vaginal  walls.  The  ute- 
rus may  be  anteverted  or  retroverted,  but  is  so  small  that  it  makes 
no  difference  what  position  it  occupies  so  long  as  it  is  kept  high 
enough  up. 

The  globe  is  easily  used.  In  fact  no  mistake  can  be  made  with 
it  except  to  use  one  that  is  too  large.  This  must  be  avoided,  be- 
cause one  that  is  too  large  will  cause  vaginitis  and  ulceration.  It 
is  a  fact  also  that  the  pessary  which  answers  when  first  used  will  be 
too  large  when  the  parts  regain  some  of  their  original  tonicity. 
For  a  time  the  patient  should  be  kept  under  observation  and  the  in- 
strument changed  to  suit.  This  globe  pessary  is  the  most  trouble- 
some instrument  to  remove.  I  have  usually  succeeded  by  using  a 
small  Sims's  speculum  and  a  Sims's  vaginal  depressor,  and  seizing 
the  instrument  between  the  two  and  making  traction.  When  this 
fails,  a  pair  of  miniature  obstetric  forceps  should  be  made  out  of 
strong  copper-wire,  by  doubling  it  to  form  loops  and  twisting  the 
ends  to  make  the  handles.  "With  this  the  globe  is  very  easily 
grasped  and  removed.  The  intra- vaginal  pessaries,  such  as  the  ring 
and  globe  already  mentioned,  and  all  others  that  rest  wholly  within 
the  vagina  are  liable  to  slip  down  and  give  the  patient  great  dis- 
comfort, and  sometimes  they  come  away  entirely.  This  is  especially 
the  case  when  first  introduced.  To  obviate  this,  a  perineal  band 
should  be  worn  until  the  perinseum,  upon  which  the  pessary  de- 
pends for  support,  regains  its  tonicity.  By  this  arrangement  the 
same  results  are  obtained  as  by  the  use  of  the  cup  and  stem  pessary, 
to  be  noticed  hereafter — in  fact,  better  results  so  far  as  the  comfort 
of  the  patient  and  the  final  effects  are  concerned ;  therefore,  I  have 
always  endeavored  to  relieve  prolapsus  when  possible  by  the  intra- 
vaginal  pessary. 

Several  uterine  supporters  have  been  devised  to  meet  the  require- 
ments of  cases  in  which  the  pelvic  floor  is  relaxed  from  long  disten- 
tion, so  that  it  has  not  power  to  sustain  a  pessary  in  position,  and 
the  patient's  circumstances  will  not  permit  long  rest  in  the  recum- 
bent position  and  the  use  of  the  tampon. 

They  are  all  constructed  on  similar  principles  of  mechanism  and 
action — namely,  cup  and  ring  to  receive  the  cervix  uteri,  and  a  stem 
attached  which  projects  from  the  vagina  and  is  fastened  to  a  perineal 
band,  which  in  turn  is  attached  to  a  waistband.  The  advantages 
claimed  for  this  kind  of  uterine  supporter  are  that  if  properly  ad- 
21 


306 


DISEASES   OF   WOMEN. 


justed  it  will  certainly  keep  the  uterus  in  place,  and  the  patient  can 
remove  and  readjust  it  when  desirable.  These  are  valuable  features 
no  donbt,  and  may  be  fairly  claimed  for  the  instrument  as  a  rule, 
but  not  without  many  exceptions.  There  are  cases  where  this  form 
of  instrument,  while  it  will  keep  the  uterus  at  its  proper  elevation, 
Avill  not  keep  it  in  its  proper  axis  without  very  great  care  in  its  ad- 
justment. Under  such  circumstances  the  patient  can  not  remove  and 
replace  the  pessary  with  any  satisfactory  results.  While  pushing  up 
the  uterus,  during  the  introduction  of  the  pessary,  a  retroversion 
takes  place,  and  wearing  the  instrument  only  aggravates  that  form  of 
displacement.  The  further  objections  which  may  be  placed  over 
against  the  advantages  of  this  kind  of  pessary  are  that  it  can  not 
be  worn  for  any  great  length  of  time  without  doing  harm  and  caus- 
ing great  discomfort,  and  where  in  a  given  case  the  patient  can  not 
adjust  it  properly  herself  it  will  do  more  harm  than  good,  and  should 
not  be  employed  on  any  account  under  these  conditions.  Again,  in 
the  most  favorable  cases,  it  is  a  constant  source  of  irritation,  less  or 
more.  The  vulva  is  irritated  by  its  presence  and  usually  becomes 
inflamed  in  time ;  the  pressure  of  the  cup  against  the  cervix  and 
upper  end  of  the  vagina  causes  inflammation  and  ulceration,  if  the 
patient  takes  much  active  exercise.  The  reason  for  this  is  that  the 
pessary  is  firmly  fixed  by  its  support  outside  of  the  body  and  the 
movements  of  the  pelvic  organs  against  this  fixed  instrument  cause 
great  friction.  The  intra- vaginal  pessary  moves  with  the  pelvic 
organs,  but  the  stem  pessary  does  not  accom- 
modate itself  to  the  requirements,  and  hence 
its  power  to  do  harm. 

From  the  little  that  has  been  said,  it  will 
appear  that  the  use  of  the  vaginal  stem  pes- 
sary for  the  relief  of  prolapsus  is  most  unsat- 
isfactory.    All  that  can  be  said  of  such  means 
of  support  is,  that  in  some  cases  they  may  be 
used  for  a  time  in  the  hope  of   helping  to 
restore   the   natural   uterine   supports.      Dr. 
Paul  F.  Munde  has  truly  said,  "  The  ideal 
pessary  for  complete  prolapsus  uteri  is  yet 
undiscovered."    The  instrument  which  I  have 
found  to  answer  best  of  the  stem  pessaries  is 
a  modiflcation  of  Cutter's  (Fig.  140). 
These  pessaries  should  be  fitted  with  care,  and  just  here  another 
difficulty  is  encountered  in  the  fact  that  they  are  all  made  of  one 
size  and  shape,  so  that  it  is  difficult  to  change  them  to  suit  special 


Fig.   116. — Stem  pessary. 
Modification  of  Cutter's. 


DISLOCATIONS   OF  THE   UTERUS.  30T 

cases.  This  I  have  tried  to  overcome  by  making  the  stem  flexible, 
or  rather  so  that  it  can  be  molded,  and  capable  of  being  shortened, 
so  that  it  can  be  made  to  suit  each  case. 

Fortunately,  stem  pessaries  are  rarely  needed,  and,  I  may  say, 
that  every  year  I  tind  less  need  for  them. 

By  a  careful  and  judicious  use  of  the  ring  and  the  tampon,  aided 
by  the  T-bandage  to  suj)port  the  pelvic  floor,  one  can  accomplish 
nearly  all  that  can  be  done  by  these  artificial  supports. 

The  important  facts  in  connection  with  pessaries  already  men- 
tioned, may  be  recapitulated  here,  and  they  should  be  borne  in  mind. 
They  are  as  follows :  First,  these  means  of  relief  for  prolapsus  most- 
ly are  temporary  and  palliative,  and  can  only  keep  the  uterus  in 
place  until  the  tissues  are  prepared  for  the  operation  of  perineor- 
raphy  when  the  pelvic  floor  has  been  injured  ;  second,  they  keep 
the  uterus  in  place  till  the  normal  supports  are  restored ;  and,  third, 
they  reduce  a  complete  prolapsus  to  an  incomplete,  when  an  intra- 
vaginal  pessary  will  answer  the  purpose. 

While  these  artificial  means  of  support  are  being  employed,  ef- 
forts should  be  made  to  strengthen  the  parts  and  to  remove  all  com- 
plications which  tend  to  keep  up  the  prolapsus,  astringent  injections 
should  be  continued,  standing  and  walking  should  be  hmited  to  an 
amount  which  is  sufiicient  for  exercise,  and  lifting Jieavy  weights 
and  wearing  tight  and  heavy  clothing  should  be  avoided.  The  bow- 
els should  be  kept  free,  so  that  straining  at  stool  may  be  unneces- 
sary. This  last  point  should  be  carefully  attended  to.  Constipation 
is  a  potent  cause  in  producing  and  keeping  up  prolapsus.  The  gen- 
eral health  should  be  cared  for,  and  if  there  is  any  debility  it  should 
be  met  by  the  proper  tonic  treatment. 

In  some  of  the  most  favorable  cases  complete  relief  will  be  ob- 
tained by  the  means  described,  so  that  all  mechanical  supports  can 
be  given  up.  Care  should  be  taken  not  to  remove  the  pessary  too 
soon.  I  have  found  in  cases  of  prolapsus  that  it  is  best  to  reduce 
the  size  of  the  pessary  by  changing  from  time  to  time  to  a  smaller 
one. 

Martin,  of  Berlin,  has  reported  one  hundred  and  ninety-two  cases 
in  which  he  has  operated  for  the  cure  of  prolapsus.  In  all  but  six 
he  was  obliged  to  perform  an  operation  upon  the  cervix ;  in  three 
instances  it  was  necessary  to  extii'pate  the  entire  uterus.  In  one 
hundred  and  seventy-one  cases  silk  sutures  were  used,  in  seventeen 
the  continuous  catgut,  the  latter  being  highly  commended,  al- 
though it  is  noted  that  it  is  not  safe  to  depend  entirely  upon  these, 
as  secondary  haemorrhage  may  occur  if  they  are  not  re-enforced  with 


308  DISEASES   OF   WOMEN. 

silk.  Relapses  occurred  only  eleven  times,  and  those,  too,  in  old 
subjects.  The  operations  performed  were  anterior  and  posterior 
kolporrhapliy,  with  perineorrhaphy. 

In  comparing  my  own  results  with  the  above,  I  find  that  I  have 
succeeded  as  well  by  the  combined  use  of  mechanical  supports  and 
surgical  operations.  That  in  the  treatment  of  prolapsus,  where  op- 
erating upon  the  cervix  uteri  and  pelvic  floor  has  failed,  kolpor- 
rhaphy  has  also  been  useless.  I  have,  therefore,  abandoned  tliat  op- 
eration. 


TREATMENT   OF   PROLAPSUS   BY   GALVANO-CAUTERY. 

Dr.  John  Byrne,  of  Brooklyn,  has  treated  successfully  nine  cases 
of  prolapsus  of  the  uterus  by  galvano-cautery.  In  three,  the  cervix 
uteri  was  completely  amputated  with  the  galvano-cautery.  The 
other  six  were  treated  by  partial  amputation  of  the  cervix.  The  de- 
scription of  the  operation  is  given  by  Dr.  Byrne  as  follows : 

"  A  diverging  double  tenaculum  was  passed  into  the  cervical 
canal  and  fixed  in  the  tissues  so  as  to  secure  complete  control  of  this 
part.  The  entire  mass  was  next  returned  within  the  pelvic  cavity, 
and  the  uterus  elevated  sufficiently  to  show  the  line  of  vaginal  in- 
sertion in  its  entire  circumference.  While  in  this  position,  a  small 
platinum  knife,  brought  to  a  red  heat,  was  slowly  carried  around  the 
base  of  the  cervix,  close  up  to  the  vaginal  fold,  and  to  a  depth  suffi- 
cient to  accommodate  a  platinum  loop,  and  to  insure  it  against  slip- 
ping. The  latter  was  next  adjusted,  and  the  amount  of  battery  im- 
mersion being  duly  estimated  to  guard  against  overheating  of  the 
wire,  the  loop  was  slowly  and  with  intermissions  contracted,  until 
about  one  quarter  of  an  inch  in  depth  had  been  reached.  The  wire 
was  now  removed,  and  a  firmly-rolled  tampon,  one  and  a  half  inch 
in  diameter  and  four  inches  long,  smeared  with  glycero-tannin, 
having  four  per  cent  of  carbolic  acid,  was  passed  into  the  vagina, 
and  a  T-bandage  applied." 

Two  of  the  six  cases  required  linear  cauterization  of  the  vagi- 
nal walls  as  well  as  partial  amputation.  The  following  is  Dr. 
Byrne's  description  of  the  operation : 

"  The  parts  having  been  returned  as  in  the  former  case,  the  line 
of  vaginal  insertion  was  noted,  and  merely  marked  in  spots  by  the 
cautery  knife.  The  entire  mass  was  then  brought  down  and  out, 
and  with  the  same  instrument  a  deep,  circular  fissure  about  three 
eighths  of  an  inch  in  depth  was  made  around  the  entire  circumfer- 
ence of  the  cervix,  the  knife  being  carried  upward  and  inward  in 


DISLOCATIONS   OF  THE  UTERUS.  309 

the  direction  of  the  os  internum,  and  precisely  as  I  am  accustomed 
to  do  in  suitable  cases  of  carcinoma.  This  being  done,  three  diverg- 
ing fissures  were  made,  one  central,  one  toward  either  side  on  the 
anterior,  and  one  only  on  the  rectal  surface,  starting  from  and  con- 
necting with  the  circular  incision  for  a  distance  of  about  three 
inches  ;  care  being  taken  that  the  entire  depth  of  the  hypertrophied 
vaginal  membrane  should  be  incised." 

I  am  unable  to  speak  from  experience  regarding  this  method  of 
treating  prolapsus  of  the  uterus.  The  histories  of  the  cases  given 
by  Dr.  Byrne  in  the  "  Transactions  of  the  American  Gynecological 
Society  "  for  1886,  axe  very  satisfactory. 


CHAPTEE   XYIII. 

EETKOVEESIOX    OF    THE    UTEEU8. 

Retroteesiox  of  the  uterus  is  a  change  in  the  axis  of  that  organ 
in  which  the  fundus  points  toward  the  sacrum  and  the  cervix  turns 
toward  the  symphysis  pubis  or  vaginal  outlet.  This  displacement 
varies  in  extent  in  different  cases  ;  three  degrees  are  usually  de- 
scribed. In  the  tirst  degree  the  fundus  points  toward  the  promon- 
tory of  the  sacrum  ;  in  the  second  the  uterus  lies  almost  transversely 
in  the  pelvis ;  and  in  the  third  the  fundus  is  low  down  in  the  pel- 
vis, while  the  cervix  is  thrown  upward  at  a  higher  elevation  than 
the  fundus. 

Retroversion  is  usually  progressive,  except  in  the  first  months  of 
pregnancy  and  in  the  puerperal  state.  In  these  conditions  retrover- 
sion may  occur  abraptly,  and  so  it  may  under  other  circumstances, 
but  usually  it  comes  on  gradually,  passing  from  the  first  degree  to 
the  second,  and  on  to  the  third. 

It  is  exceedingly  rare  to  find  retroversion  in  the  first  degree  ex- 
isting for  any  length  of  time,  the  displacement  usually  passing  on  to 
the  second  and  third  degrees. 

The  anatomical  changes  which  take  place  in  backward  displace- 
ments are  to  some  extent  the  same  as  those  found  in  prolapsus. 
The  same  changes  in  the  supports  of  the  uterus  are  found,  and 
though  differing  in  detail  are  the  same  in  kind.  This  arises  from 
the  fact  that  nearly  every  case  of  prolapsus  is  associated  with  more 
or  less  retroversion,  and  in  nearly  all  cases  of  retroversion  there  is 
also  a  slight  prolapsus.  These  changes  have  been  discussed  under 
the  head  of  prolapsus,  hence  it  is  only  necessary  for  me  to  point 
out  here  the  anatomical  features  which  are  ^particularly  concerned 
in  retroversion. 

In  retroversion  there  is  shortening  of  the  posterior  vaginal  wall 
by  contraction.  The  exceptions  to  this  are  when  there  is  rectocele, 
and  in  recent  cases  in  which  the  vaginal  wall  is  apparently  short- 

310 


EETROVERSION    OF   THE   UTERUS. 


311 


ened,  but  in  reality  is  thrown    into  folds.     The    anterior   vaginal 
wall  is  generally  distorted  rather  than  displaced.     Its  upper  end  is 


Fig.  l-i'Z. — The  three  decrees  of  retroversioii. 


crowded  upward  and  sometimes  forward  by  the  cervix  uteri,  and  its 
lower  part  is  sometimes  pressed  downward  and  forward,  giving  it 
the  appearance  of  a  urethrocele. 

The  relations  of  the  cervix  and  vagina  are  changed  more  or  less 
in  the  majority  of  cases.  In  some  the  projection  of  the  cervix  into 
the  vagina  is  apparently  very  much  increased  posteriorly.  To  the 
touch  the  vagina  appears  to  be  attached  to  the  whole  length  of  the 
cervix.  This  is  apparent,  not  real,  and  is  usually  found  so  when 
the  vagina  has  still  maintained  its  tonicity.  In  other  cases,  with 
marked  shortening  of  the  vaginal  wall,  the  invagination  of  the  cer- 
vix is  lessened.  IN  early  always  the  invagination  of  the  cervix  ante- 
riorly is  less  than  normal.  The  position  of  the  uterus  as  regards 
elevation  varies  greatly  in  diiJerent  cases.  This  may  be  normal  in 
the  pelvis,  simply  changed  in  its  axis,  or  it  may  be  prolapsed  so  that 
the  cervix  is  close  to  the  vulva,  the  anterior  vaginal  wall  being  much 
shortened.     Again,  the  posterior  wall  of  the  uterus  may  rest  upon 


312 


DISEASES   OF   WOMEN. 


the  pelvic  floor  and  altogetlier  be  placed  far  back  in  the  pelvis,  so 
that  the  fundus  presses  upon  the  rectum,  while  the  bladder  may  not, 


Fig.   148. — Retroversion  of  the  second  decree. 


as  a  rule,  be  much  affected,  either  in  its  position  or  function,  though 
it  sometimes  is.  The  pressure  of  the  uterus  being  removed  from 
behind,  there  is  nothing  except  the  vesical  ligaments  to  prevent  the 
bladder  from  extending  backward  when  distended.  It  then  rests 
upon  the  retrovertcd  uterus  instead  of  rising  up  toward  the  abdomi- 
nal cavity,  and  the  ovaries  and  Fallopian  tubes  are  to  some  extent 
carried  backward  and  downward  with  the  uterus.  The  extent  of 
this  displacement  varies  greatly.  In  some  cases  there  is  complete 
prolapsus  of  one  ovary,  or  of  both  of  these  organs,  so  that  they  lie  in 
the  sac  of  Douglas  and  the  uterus  rests  upon  them.  In  other  cases 
the  ovaries  rest  upon  the  retrovertcd  uterus.     One  case  of  this  kind 


KETROVERSION   OF  THE   UTERUS.  313 

I  well  remember  to  have  operated  upon.  The  ovaries  were  diseased 
and  gave  so  much  trouble  that  I  decided  to  remove  them.  One  was 
in  its  normal  position,  the  other,  the  right  one,  was  adherent  to  the 
side  of  the  uterus.  This  prolapsus  of  the  ovaries  is  one  of  the 
worst  complications  of  retroversion. 

There  is  a  strongly-prevailing  opinion  that  the  circulation  in  the 
pelvic  organs  is  much  deranged  by  retroversion,  and  that  changes  of 
structure  of  these  organs  follow  in  consequence.  How  far  this  is  a 
fact  it  is  difficult  to  determine.  It  is  true  that  in  nearly  all  cases  of 
retroversion  are  found  some  congestive  inflammatory  trouble  and 
structural  changes,  either  from  degeneration  or  hyperplasia,  but 
whether  these  changes  preceded  the  version  and  perhaps  aided  in 
producing  it,  or  whether  they  resulted  from  the  change  of  position, 
can  not  at  all  times  be  ascertained.  There  is  good  reason  for  be- 
lieving that  all  malpositions  cause  deranged  nutrition  which  in  time 
lead  to  organic  changes,  and  still  such  pathological  conditions  are 
found  when  there  is  no  displacement,  showing  that  these  relations  of 
cause  and  effect  are  interchangeable  in  displacements  and  some  other 
diseases  of  the  uterus. 

COMPLICATIONS. 

There  are  cases  of  retroversion  so  complicated  that  they  are  per- 
manent and  incurable.  These  should  be  clearly  understood  ;  hence 
I  refer  to  them  briefly  in  this  connection. 

There  are  two  classes  of  such  cases  :  Those  which  have  had  pel- 
vic peritonitis  while  the  uterus  was  retro  verted,  the  adhesions  made 
by  the  products  of  the  inflammation  permanently  fixing  the  uterus 
in  its  malposition.  I  presume  that  a  similar  result  is  sometimes 
produced  by  pelvic  peritonitis,  the  products  of  which  (behind  the 
uterus)  will  by  contracting  drag  the  uterus  into  the  position  of  re- 
troversion. This  complicated  form  of  retroversion  has  been  con- 
sidered incurable,  but  recently  encouraging  efliorts  have  been  made 
to  relieve  it  by  surgical  treatment.  This  subject  will  be  referred 
to  and  discussed  at  the  end  of  this  chapter.  The  other  class  is 
one  in  which  a  similar  condition  occurs  as  the  result  of  malfor- 
mation or  congenital  malposition.  In  cases  of  this  kind  the  uterus 
is  retroverted,  the  posterior  vaginal  wall  short  and  rigid,  the  utero- 
sacral  ligaments  are  short  and  rather  unyielding,  and  although  the 
uterus  is  slightly  movable  it  can  not  be  restored  to  its  proper  place. 
In  such  case  the  pelvis  is  wide  and  shallow,  and  there  is  often  a 
lack  .of  cellular  tissue  around  the  pelvic  organs.  When  I  first  had 
my  attention    directed  to  this  class  of  cases  I  presumed  that  they 


314  DISEASES   OF  WOMEN. 

must  have  had  pelvic  peritonitis,  but  in  many  of  them  there  was 
no  evidence  obtained  from  the  past  history  to  warrant  any  such 
conclusion.  Further  investigation  satisfied  me  that  the  lesions 
were  the  result  of  perverted  development  and  growth.  Some  of 
these  cases  do  not  suffer  much,  but  they  are  sterile  as  a  rule. 

Symptomatology. — The  clinical  history  of  retroversion,  so  far  as 
the  symptoms  are  concerned,  is  not  sufficiently  definite  to  be  diag- 
nostic. Many  of  the  symptoms  are  common  to  prolapsus  and  cer- 
tain other  affections  of  the  utems.  Another  curious  fact  is  that 
the  suffering  caused  by  retroversion  varies  greatly  in  different  pa- 
tients. The  rule  is  that  retroversion  causes  much  discomfort,  but  I 
have  seen  one  patient  who  had  retroversion  for  many  years  and  yet 
was  one  of  the  most  active  women  I  have  ever  known,  and  was  per- 
fectly free  from  all  symptoms  of  any  affection  of  tlie  pelvic  organs. 

The  symptoms  which  belong  more  especially  to  retroversion  are 
rectal  tenesmus  and  the  feeling  of  obstruction  to  a  free  action  of  the 
bowels. 

Backache,  general  pelvic  tenesmus,  aching  of  the  limbs,  irritation 
of  the  bladder  and  rectum,  neuralgic  pains  in  the  pelvis,  and  the 
fact  that  these  symptoms  are  aggravated  by  walking  and  standing 
and  are  relieved  in  the  recumbent  position,  are  all  evidences  of  re- 
troversion, but  also  occur  in  prolapsus. 

Menstniation  is  frequently  deranged  and  monorrhagia,  dysmen- 
orrhoea  of  a  mild  form,  and  irregular  recurrence  of  the  menses,  have 
all  been  traced  to  this  form  of  displacement ;  but  all  these  are  more 
frequently  caused  by  other  affections.  In  several  cases  that  I  have 
seen,  the  menstrual  discharge  was  offensive  and  very  distressing  to 
the  patient.  This  symptom  I  have  noticed  more  frequently  in  retro- 
version and  retroflexion  than  in  any  other  affection  of  the  uterus. 

Physical  Signs. — The  physical  signs  are  obtained  by  the  touch 
and  uterine  sound.  The  vaginal  touch  reveals  the  os  uteri  pointing 
toward  the  introitus  vulvae,  or  in  extreme  cases,  toward  the  sym- 
physis pubis.  The  anterior  vaginal  wall  is  often  found  projecting 
doA\Tiward  in  front  of  the  cervix.  The  upper  portion  of  the  pos- 
terior vaginal  wall  is  found  to  be  pressed  downward  and  forward,  so 
that  the  junction  of  the  posterior  cervical  wall  of  the  uterus  and  the 
vagina  are  much  nearer  to  the  vulva  and  more  easily  touched  with 
the  finger.  In  some  cases  this  prolapsus  of  the  posterior  vaginal 
wall  is  very  marked,  and  appears  to  aggravate  the  version  by  push- 
ing the  cervix  against  the  bladder. 

If  the  bladder  is  empty  and  the  muscles  of  the  abdomen  are  re- 
laxed, the  bimanual  examination  will  show  that  the  uterus  is  not  in 


RETROVERSION  OF  THE   UTERUS.  315 

its  normal  position,  but  must  be  retro  verted,  as  indicated  by  the  signs 
obtained  by  the  vaginal  touch.  These  signs  of  retroversion,  while 
quite  reliable,  might,  in  rare  or  complicated  cases,  be  misleading,  so 
that  it  is  well  to  confirm  or  correct  by  the  use  of  the  sound  the  evi- 
dence obtained  by  the  touch.  Placing  the  patient  on  the  left  side 
and  using  Sims's  speculum,  the  sound  can  be  passed  with  ease,  and 
its  direction  will  show  the  dislocation  of  the  uterus. 

In  doubtful  or  complicated  cases,  when  all  the  evidence  is  needed 
that  can  be  obtained,  the  rectal  touch  may  be  employed.  The  finger 
in  the  rectum  can  be  swept  all  around  the  fundus  and  body  of  the 
uterus  while  it  lies  low  down  in  the  sac  of  Douglas  in  the  reti-o- 
verted  state.  The  rectal  touch  can  be  made  more  eifective  still  by 
making  the  abdominal  or  vaginal  touch  at  the  same  time.  By  these 
means  of  examination  a  diagnosis  can  be  made  with  the  greatest  cer- 
tainty, and  proof  of  the  accuracy  of  the  diagnosis  may  be  obtained 
by  replacing  the  uterus.  Regarding  the  conditions  which  may  be 
mistaken  for  retroversion  and  the  differentiation  little  need  be  said. 
The  question  which  most  frequently  arises  is  whether  there  is  retro- 
version or  retroflexion.  This  can  always  be  settled  by  the  evidence 
obtained  from  the  physical  signs  already  obtained,  and  the  fact  that 
in  flexion  the  uterus  is  bent  upon  itself,  a  fact  that  is  noticed  by  the 
touch  and  conflrmed  by  the  use  of  the  sound. 

Causation. — The  causes  which  produce  prolapsus  uteri  are  ap- 
parently the  same  as  those  which  give  rise  to  retroversion.  The 
reader  may  refer  back  to  the  causation  of  prolapsus  for  the  facts  re- 
garding this  matter.  This  will  save  repetition.  It  is  clearly  evident, 
however,  that  while  there  may  be  much  in  common  in  the  causation 
of  the  two  forms  of  uterine  displacement,  prolapsus  and  retrover- 
sion, there  must  be  some  difference  in  the  causes  which  produce  such 
different  effects.  This  appears  to  have  been  quite  an  obscure  sub- 
ject, for  I  find  that  the  text-books  are  very  indifferent  in  regard  to 
it.  My  own  observations  lead  me  to  believe  that  the  causes  of  re- 
troversion are  the  loss  of  support  from  morbid  states  of  the  uterine 
ligaments  occuring  while  the  pelvic  floor  remains  normal  or  not 
wholly  useless  as  a  means  of  support,  and  that  prolapsus  is  due  to 
defects  in  the  uterine  supports  and  loss  of  the  pelvic  floor  also.  This 
may  bs  stated  in  another  way,  which  will  show  what  this  view  is 
based  upon.  In  the  great  majority  of  cases  of  retroversion  which  I 
have  seen,  the  pelvic  floor  has  not  been  wholly  wanting,  in  fact,  in 
some  of  the  cases  it  has  been  quite  normal ;  while  in  prolapsus  it  is 
usually  defective.  It  will  be  easily  understood  that  when  the  sup- 
ports of  the  uterus  are  defective,  especially  the  anterior  ligaments,  and 


316 


DISEASES  OF  WOMEN. 


the  vagina  and  pelvic  floor  are  in  their  normal  condition  and  keep 
the  cervix  uteri  in  place,  the  tendency  would  be  for  the  uterus  to 
fall  backward  into  the  retro  verted  position. 

Changes  in  the  condition  of  the  cervix  uteri  and  in  its  relations 
to  the  vagina  have  some  influence  in  the  causation  of  retroversion. 
In  those  who  have  had  cellulitis,  after  confinement,  in  the  tissue 
around  the  cervix  above  the  vagina  the  invagination  of  the  cervix  is 

lessened  —  indeed,  sometimes 
obliterated. 

The  vagina  to  the  touch  is 
like  a  cul-de-sac^  the  entire 
uterus  being  above  the  vagina. 
This  condition  favors  retrover- 
sion. Fig.  149  shows  retrover- 
sion with  imperfect  invagina- 
tion of  the  cervix  uteri  in  a 
patient  who-  has  had  cellulitis. 
Laceration  of  the  cervix 
bilaterally  produces  a  similar 
condition  of  imperfect  invagi- 
nation, which  is  often  associated  with  retroversion.  The  anterior 
half  of  the  cervix  becomes  lost  in  the  anterior  vaginal  wall,  and  the 
posterior  part  of  the  cervix  is  apparently  less  prominent  in  the 
vagina,  if  not  really  so.  This  is  more  frequently  seen  where  the 
lateral  lacerations  extend  above  the 
vaginal  junction.  Fig.  150  shows 
this  condition. 


Fig.  149. — Retroversion  with  imperfect  invag- 
ination of  cervix  due  to  inflammatory 
products  about  it. 


Fig.  150. — Apparent  imperfect  invagination 
due  to  bilateral  laceration  of  cervix : 
c,  c,  lips  of  the  cervix. 


Fig.  151. — The  same  uterus  with  its 
lips  drawn  back  into  place  by 
tenacula. 


In  such  cases  the  state  of  the  cervix  has  much  to  do  with  keeping 
up  the  retroversion,  as  well  as  causing  it.    This  I  have  demonstrated 


RETROVERSION  OP   THE  UTERUS. 


317 


by  trying  to  keep  the  uterus  in  place  before  restoring  the  cervix,  and 
finding  it  very  difficult,  while  it  was  quite  easy  to  do  so  after  the 
cervix  was  restored.  The  immediate  effect  of  operating  was  to  bring 
the  cervix  prominently  into  the  vagina  and  sustain  it  there.  Fig.  151 
shows  the  change  effected  in  the  case  represented  in  Fig,  150,  after 
the  restoration  of  the  cervix  and  before  restoring  the  retroversion. 

Further  evidence  is  also  obtained  to  show  that  these  raal-relations 
of  the  vagina  and  cervix,  just  mentioned,  favor  retroversion  of  the 
uterus,  in  the  fact  that  in  those  cases  in  which  the  cervix  has  been 
amputated  the  uterus  is  generally  retro  verted. 

These  points  I  consider  to  be  of  much  importance  and  of  special 
interest  because  they  are  not,  so  far  as  I  know,  discussed  in  medical 
works  with  reference  to  the  causation  of  retroversion  of  the  uterus. 

Treatment. — The  indications  are,  to  replace  the  uterus  and  keep 
it  there,  and,  by  so  doing,  the  supports  of  the  uterus  may  regain 
their  normal  condition  and  complete  relief  follow.  The  methods 
of  replacing  the  retroverted  uterus  are  to  place  the  patient  on 
the  left  side,  and  through  Sims's  speculum  to  raise  the  body  of 
the  uterus  up  with  two  sponges  in  holders,  used  as  in  Fig.  152. 

By  upward  press- 
ure the  uterus  can 
be  raised  as  far  as 
need  be,  or  as  far  as 
possible,  and  then 
one  of  the  spong- 
es should  be  with- 
drawn or  placed  in 
front  of  the  cervix, 
and  backward  press- 
ure made  there. 
This  helps  to  com- 
plete the  replace- 
ment, and  at  the 
same  time  holds  the 
uterus  in  place, 
while  the  sponge  is 
removed  from  its 
position  behind  the 
uterus. 

To  succeed  in  this 
operation,  it  is  ne- 
cessary to  have  the 


Fig.  152. — The  three  steps  in  replacing  the  retroverted 
uterus  by  means  of  sponge-holders. 


318  DISEASES   OF   WOMEN. 

bladder  empty,  and  that  the  patient  should  not  resist  the  efforts 
of  the  suj-geon  to  replace  the  uterus.  Wlien  there  is  any  difficulty 
met  in  the  practice  of  the  method  described,  the  patient  should  be 
placed  in  the  knee-chest  position  (see  Vig.  150),  and  the  Sims's 
speculum  used.  This  alone  is  sufficient  in  some  cases  to  effect  re- 
placement. When  it  does  not  do  so,  the  upward  pressure  of  the 
sponges  behind,  or  drawing  the  cervix  back  with  a  tenaculum,  will 
accomplish  the  object,  or  both  sponge  and  tenaculum  may  be  used. 

It  is  sometimes  difficult  to  replace  the  uterus  in  cases  of  long 
standing,  owing  to  the  contraction  of  the  posterior  vaginal  wall. 
The  changes  in  the  parts  which  have  taken  place  to  accommodate 
the  malposition,  can  not  always  be  immediately  overcome.  In  such 
cases  all  that  can  be  accomplished  is  to  raise  the  uterus  as  far  toward 
its  normal  place  as  possible,  and  then  hold  it  there  by  means  of  a 
temporary  support.  By  the  use  of  the  cotton  tampon  or  a  pessary, 
all  that  is  gained  by  the  first  and  succeeding  efforts  to  replace  the 
uterus  is  kept,  and  if  the  pessary  is  used  properly  it  will  make  con- 
tinuous upward  pressure  upon  the  fundus  uteri,  and  thereby  con- 
stantly gain  more  and  more.  In  cases  of  long  standing  the  displace- 
ment becomes  completed  by  slow  degrees,  as  the  tissue  changes  in 
the  support  of  the  uterus  and  vagina  have  taken  place  as  the  result 
of  long-continued  influences,  and  they  can  not  be  abruptly  rectified. 
It  takes  time  to  undo  that  which  it  has  required  months  and  years  to 
do ;  hence,  the  process  of  restoration  must  be  accomplished  by  degrees 
and  by  repeated  efforts.  The  details  of  this  method  of  treatment 
will  be  given  in  the  clinical  histories  of  cases  to  be  related  hereafter. 

The  next  object  to  be  attained  is  to  keep  the  uterus  in  position. 
This  raises  the  question  of  the  mechanical  supports  of  the  uterus.  I 
think  that  Dr.  Frank  P.  Foster,  of  New  York,  has  given  the  most 
rational  discussion  of  the  subject  that  I  have  seen,  and  I  will  quote 
his  views  later  on. 


THE   TREATMENT   OF  RETROVERSION    BY   THE   USE   OF 

PESSARIES. 

There  are  a  great  many  kinds  of  pessaries  em])loyed  in  treating 
retroversion  of  the  uterus.  A  few  of  them  can  be  made  to  do  much 
good  when  skillfully  employed.  The  great  majority  of  them  are 
useless,  and  all  of  them  are  capable  of  doing  much  harm  if  used 
without  a  clear  idea  of  how  they  should  be  used.  During  a  discus- 
sion of  displacements  of  the  uterus  at  a  meeting  of  the  American 
Gynecological  Society  held  in  Boston,  in  1877,  Dr.  E.  R.  Peaslee 


RETROVERSION  OF  THE  UTERUS.  319 

expressed,  himself  in  favor  of  the  use  of  pessaries,  claiming,  at  the 
same  time,  to  have  obtained  very  gratifying  results  from  their  use 
in  his  own  practice.  In  the  same  discussion.  Dr.  "VV.  L.  Atlee  said  : 
"  I  have  had  no  experience  vi^ith  pessaries,  at  least  with  their  intro- 
duction, but  I  have  had  a  very  long  experience  with  theii*  removah 
I  do  not  think  that  there  is  a  day  when  I  am  at  home  and  in  my 
office,  that  I  do  not  have  the  privilege  of  taking  out  a  pessary.  I 
have  removed  pessaries  of  all  forms  and  sizes,  and  pessaries  intro- 
duced by  the  most  distinguished  men  of  the  profession."  Peaslee 
and  Atlee  were  certainly  two  members  of  the  profession  of  this 
country,  equally  distinguished  in  abihty,  profound  judgment,  and 
thorough  honesty,  and  why  they  should  hold  such  opposing  views 
upon  a  subject  so  practical  may  not  be  capable  of  explanation  by 
any  one.  It  has  appeared  to  me,  however,  that  the  one  came  to  his 
conclusions  from  a  careful  investigation  of  the  utility  of  pessaries 
when  properly  used,  while  the  other  based  his  opinions  upon  the 
fact  that  as  generally  employed,  pessaries  do  very  great  harm. 
Viewing  the  subjects  from  these  two  stand-points,  both  conclusions 
are  perfectly  rational,  and  ample  proof  may  easily  be  obtained  of 
the  good  and  evil  which  come  from  the  use  of  these  instruments. 

At  the  present  day,  I  presume  that  if  the  harm  done  should  be 
placed  opposite  the  good  accomplished  by  all  the  pessaries  in  use, 
the  results  would  be  about  equally  balanced.  It  follows,  then,  that 
as  matters  stand  at  this  moment,  it  is  a  question  whether  the  human 
race  would  be  better  or  worse  if  all  the  pessaries  were  j)ut  out  of  ex- 
istence. 

The  all-important  fact  remains,  however,  that  pessaries  are  of 
great  value,  and  capable  of  giving  relief  to  those  who  suffer  from 
some  of  the  forms  of  uterine  displacements,  if  properly  used.  The 
same  may  be  said  of  nearly  all  valuable  agents  employed  for  the  re- 
lief of  suffering.  That  any  agent,  capable  of  giving  relief  when 
skillfully  employed,  is  likely  to  be  as  potent  for  evil  when  misused, 
is  a  well-known  fact ;  hence,  the  object  should  be  to  attain  to  a  more 
perfect  and  general  knowledge  of  how  to  make  and  use  pessai'ies  in 
order  to  promote  the  good  results,  and  lessen  the  evil. 

There  are  many  difficulties  which  naturally  arise  in  the  investi- 
gation of  the  use  of  pessaries.  Not  only  do  authorities  differ  very 
widely  in  their  views  regarding  their  use,  but  one's  own  experience 
is  oftentimes  misleading.  For  example,  a  pessary  may  be  used  to 
correct  a  displacement,  and  marked  rehef  is  obtained.  The  patient 
testifies  to  the  fact  that  her  symptoms  are  relieved  and  her  useful- 
ness extended  while  wearing  a  pessary,  and  yet  that  instrument  may 


320  DISEASES  OF  WOMEN. 

be  doing  harm  by  still  further  damaging  the  supports  of  the 
uterus. 

These  may  appear  like  contradictory  statements,  and  yet  such  are 
the  facts  observed  many  times  in  practice.  The  same  thing  is  seen 
in  the  abuse  of  corsets.  The  lady  who  has  contracted  her  waist  by 
tight  lacing  suffers  great  discomfort  when  she  goes  without  corsets, 
and  is  relieved  by  wearing  them,  and  yet  no  one  doubts  the  fact  that 
great  injury  is  caused  by  this  article  of  wearing-apparel. 

The  mechanical  action  of  pessaries  must  necessarily  be  clearly 
understood  in  order  that  they  may  be  employed  with  favorable  re- 
sults ;  misunderstanding  on  this  point  is  no  doubt  the  cause  of  much 
unsatisfactory  practice.  Judging  from  the  many  errors  made  in  the 
use  of  pessaries,  as  seen  in  practice  and  from  the  various  opinions 
expressed  by  writers,  I  am  fully  satisfied  that  this  part  of  the  subject 
is  not  as  clearly  understood  as  it  should  be  by  the  profession  gener- 
ally. My  own  views  are  so  fully  in  accord  with  those  of  Dr.  Foster, 
that  I  shall  quote  his  article : 

"  It  can  not  be  said  that  opinions  are  wholly  agreed  as  to  the  way 
in  which  vaginal  pessaries  most  commonly  effect  changes  in  the 
sitTuation,  form,  and  attitude  of  the  uterus.  Those  who  have  given 
any  considerable  amount  of  thought  to  the  matter  will  probably  ad- 
mit (1)  that  a  pessary  may  operate  by  virtue  of  mere  lateral  disten- 
tion of  the  vagina,  being  itself  too  bulky  to  escape  readily  from  the 
pelvic  outlet,  and  thus  preventing  the  parts  resting  upon  it  from  so 
escaping ;  (2)  tliat  the  pressure  exerted  by  a  pessary  may  be  trans- 
mitted directly  to  the  body  of  the  uterus,  lifting  it  up  when  ante- 
verted  or  retroverted,  as  the  case  may  be  ;  and  (3)  that  such  pressm'e 
may  operate  by  dragging  the  lower  portion  of  the  organ  in  a  certain 
direction,  thus  causing  its  upper  portion  to  move  in  the  opposite 
direction. 

"  Wliile  there  can  scarcely  be  a  doubt  that  each  one  of  these 
methods  of  action  may  explain  the  work  done  by  pessaries  under 
certain  circumstances,  it  may  be  not  only  interesting  as  a  mere 
matter  of  cunosity,  but  prolitable  as  tending  to  greater  precision  in 
practice,  to  inquire  into  the  relative  frequency  with  which  the  one 
or  the  other  actually  operates,  which  of  them  is  therefore  of  the 
greater  practical  im])ortance,  and  which  of  them  should  be  specially 
emphasized  in  teaching.  The  question  as  to  whether  certain  pes- 
saries act  as  levers,  or  whether  they  are  merely  forced  bodily  in  a 
certain  direction,  and  so  fulfill  their  purpose,  is  quite  foreign  to  this 
inquiry,  and,  therefore,  I  shall  not  enter  upon  its  considerations. 

"  In  regard  to  the  method  of  action  first  mentioned — that  of  lateral 


RETROVERSION   OF   THE   UTERUS.  321 

or  transverse  distention  of  the  vagina — it  may  simply  be  said  to  apply 
only  to  special  forms  of  pessaries,  which,  although  in  common  use 
before  Hodge's  time,  have  now  almost  fallen  into  disuse — deservedly, 
I  may  be  allowed  to  add. 

"  The  second  method,  that  of  pressure  transmitted  directly  to  the 
body  of  the  uterus,  is  undoubtedly  the  one  that  is  most  prominent 
in  men's  minds,  most  taken  into  account  in  practice,  and  most  ap- 
pealed to  in  teaching.  And  yet,  it  seems  to  me,  its  scope  is  really 
quite  limited,  and  its  practical  importance  almost  nil.  If  an  ex- 
treme mal  posture  of  the  uterus  is  corrected  by  the  act  of  inserting 
a  pessary  adapted  to  the  case,  as  may  often  enough  be  done,  the  in- 
strument may  act  at  iirst,  I  admit,  by  direct  transmission  of  its  press- 
ure to  the  body  of  the  organ  lifting  the  latter  from  a  state  of  ex- 
treme anteversion  or  retroversion,  as  the  case  may  be.  But  such 
action  is  only  momentary ;  long  before  it  could  restore  the  uterus  to 
its  normal  attitude  another  agency  is  called  into  play,  so  that  when 
the  full  action  of  the  pessary  is  attained,  its  pressure  is  no  longer 
transmitted  to  the  body  of  the  organ.  In  any  case,  then,  this  direct 
action  on  the  body  of  the  uterus  is  of  but  momentary  duration,  and 
accomplishes  but  a  partial  result ;  and,  if  the  malposture  is  not 
originally  very  decided,  or  if  it  is  corrected  before  the  instrument  is 
inserted  into  the  vagina,  it  does  not  come  into  play  at  all. 

"  These  statements  embody  no  novelty,  but  they  are  so  at  variance 
with  the  views  that  seem  to  be  held  by  the  most  influential  teachers 
of  gynecology,  that  it  seems  best  to  put  forward  som-C  reasons  for 
them.  To  illustrate,  then,  suppose  a  case  of  retroversion.  In  order 
that  a  pessary  may  fully  restore  the  uterus  to  its  normal  attitude, 
and  hold  it  in  such  attitude  (acting  all  the  time  by  direct  pressure  on 
the  body  of  the  organ),  its  pressure  must  be  exerted  not  only  upward, 
but  forward,  and  that,  too,  at  a  point  situated  high  in  the  pelvis. 
Now,  from  my  own  experience,  from  observation  of  the  practice  of 
others,  and  from  the  drawings  employed  by  authors  to  illustrate  the 
action  of  pessaries,  I  believe  that  pessaries  long  enough  to  fulfill 
these  conditions  are  seldom  if  ever  used.  Granting,  however,  that  I 
may  be  mistaken  in  this  respect,  it  will  scarcely  be  disputed  that 
either  such  a  pessary,  besides  being  very  long,  must  have  a  very 
pronounced  curve  in  order  to  enable  its  middle  portion  to  lie  wholly 
below  the  face  of  the  cervix  while  its  upper  end  exerts  the  pressure 
in  question  (in  which  case  its  introduction,  supposing  the  periniBum 
to  be  intact,  would  be  well-nigh  impossible) ;  or  else  its  limbs  must 
diverge  to  such  an  extent  as  to  accommodate  the  cervix  between 
them,  making  the  instrument  very  broad,  in  which  case  it  would  not 
22 


322  DISEASES  OF  WOME?^. 

pass  between  the  two  utero-saeral  ligaments  without  stretching  them 
apart  to  such  a  degree  as  practically  to  shorten  them,  thus  causing 
them  to  pull  the  lower  poiiion  of  the  uterus  backward,  and  conse- 
quently throw  its  upper  portion  forward.  The  result  of  this  latter 
state  of  things  would  be  that  the  retroversion  would  be  corrected 
before  the  upper  end  of  the  instrument  had  been  forced  high  enough 
to  restore  the  body  of  the  uterus  to  its  normal  position  by  direct 
pressure  upon  it,  or  by  pressure  directly  transmitted  to  it.  Further 
than  this,  I  believe  that  in  the  great  majority  of  instances  the  mere 
upward  and  backward  pressure  upon  the  posterior  vault  of  the 
vagina  would  suffice  to  drag  the  cervix  backward  in  the  same  way 
before  the  instrument  had  penetrated  at  all  into  the  space  included 
between  the  utero-sacral  ligaments.  This,  however,  would  depend 
upon  the  degree  of  tonicity  with  which  the  vagina  was  endowed. 

"  With  regard  to  anteversion  the  case  is  even  stronger,  while  at 
the  same  time  it  is  simpler,  for  the  anterior  wall  of  the  vagina  is 
naturally  tense,  and  its  tension  is  usually  heightened  by  the  mere 
fact  of  the  uterus  being  in  a  state  of  anteversion.  In  this  tense 
condition  of  the  anterior  vaginal  wall  we  have  a  marked  contrast 
with  the  posterior  wall ;  the  latter  is  much  longer  than  a  straight 
line  drawn  between  its  two  extremities,  and  its  lower  end  is  con- 
nected with  parts  that  are  comparatively  mobile  ;  the  former  is  firmly 
attached  to  the  pubic  arch.  By  reason  of  this  tension  of  the  an- 
terior wall  of  the  vagina,  its  virtual  shortening  occurs  almost  at  once 
whenever  any  noteworthy  pressure  is  made  upon  it :  hence,  any  of 
the  various  forms  of  anteversion  pessaries  that  are  supposed  to  act 
by  lifting  the  body  of  the  utenis  directly  up,  really  accomplish  its 
ascent  by  stretching  the  anterior  wall  of  the  vagina,  and  thus  drag- 
ging the  cervix  forward.  In  proof  of  this  statement,  witness  the 
insignificant  size  of  the  anterior  projections  of  these  instruments — 
projections  utterly  incapable  of  reaching  to  the  height  that  they 
would  have  to  reach  in  order  to  make  direct  pressure  upon  the  body 
of  the  uterus,  even  with  the  bladder  intervening,  when  the  organ 
had  approached  anywhere  near  its  normal  position.  The  great  sen- 
sitiveness of  the  anterior  vaginal  wall  to  pressure,  the  well-known 
liability  of  ulceration  to  occur  upon  it  under  the  pressure  of  a  pes- 
sary, both  point  to  its  greater  tension  as  compared  with  the  posterior 
wall. 

"  Passing  now  to  the  third  of  the  various  methods  of  action  that  I 
have  attriliuted  to  pessaries — that  of  traction  upon  the  lower  portion 
of  the  uterus — but  little  need  be  said  about  it,  for  the  considerations 
brought  forward  to  show  the  limited  scope  of  the  direct-pressure 


RETROVERSION    OF   THE   UTERUS. 


323 


theory,  all  conspire  to  advance  the  traction  theory  to  the  most  im- 
portant position.  Such  I  believe  it  ought  to  occupy,  unless  the 
statements  I  have  put  forth  are  shown  to  be  erroneous.  I  will 
simply  add  that  always  in  anteversion,  and  usually  in  retroversion,  it 
is  throuajh  the  medium  of  the  vaginal  wall,  in  my  opinion,  that  pes- 
saries make  traction  upon  the  cervix. 

"  I  will  briefly  mention  some  of  the  practical  applications  of  the 
doctrine  I  have  sought  to  uphold.  In  cases  of  retroversion  it  is 
usually  sufficient  if  pessaries  are  to  be  used  at  all,  to  employ  an  in- 
strument simply  with  the  idea  of  making  backward  pressure  upon 
the  posterior  wall  of  the  vagina,  directing  the  pressure  somewhat 
upward,  unless  there  are  special  reasons  for  not  doing  so,  but  not 
resorting  to  pessaries  with  such  an  exaggerated  pelvic  curve  as  to 
render  their  introduction  difficult.  If  the  instrument  is  curved 
rather  sharply  at  a  point  very  near  its  upper  end,  the  pressure  wiU 
be  distributed  more  evenly  over  the  posterior  vault  of  the  vagina, 
and,  therefore,  will  be  borne  better. 

"  The  usual  forms  of  retroversion  pessaries  (the  Hodge  instrument 
and  its  various  modiflcations,  including  those  with  external  support) 
seem  to  me  to  act  in  this  way,  and 
to  be  as  unobjectionable  as  any  we 
are  likely  to  hit  upon.  More  or 
less  stretching  of  the  posterior 
vault  of  the  vagina  is  apt  to  re- 
sult, but  it  is  of  little  consequence 
even  should  it  prove  pei-manent, 
for  it  in  no  wise  interferes  with  the 
natural  functions  of  the  parts. 
Broad  pessaries,  penetrating  between  the  utero-sacral  ligaments, 
should  never  be  used,  for  these  ligaments  form  a  part  of  the  mech- 
anism by  which  the  normal  situation  and  attitude  of  the  uterus  are 
maintained,  and  anything  that  stretches  and  relaxes  them  interferes 
with  the  permanent  cure  of  retroversion." 


Fig.  153. — Albert  Smith  pessary. 


ADAPTATION    OF    PESSARIES. 

The  adaptation  of  pessaries  for  the  relief  of  retroversion,  is  facili- 
tated by  keeping  in  mind  the  object  to  be  accomplished,  and  the  way 
in  which  the  instrument  acts  in  fulfilling  these  requirements.  All 
that  remains,  then,  is  to  shape  the  pessary  to  the  case  in  hand,  and 
to  place  it  in  position  after  the  uterus  has  been  restored  to  its  place. 
This  is  an  easy  or  difficult  task,  according  to  the  artistic  and  me- 
chanical skill  of  the  surgeon.     Badly-adjusted  pessaries  are  not  so 


324  DISEASES  OE  WOMEN, 

common  as  badly-fitting  shoes  and  clothes,  because  they  are  not  so 
generally  used.  No  one  who  is  destitute  of  some  knowledge  and 
skill  in  mechanics,  will  ever  succeed  in  the  treatment  of  displace- 
ments of  the  uterus  by  means  of  mechanical  supports.  The  gravest 
errors  are  committed  every  day  by  using  pessaries  without  under- 
standing the  principle  of  their  action  or  the  methods  of  adapting 
them.  This  lack  of  knowledge  and  of  the  required  ability  lead  to 
the  too  frequent  use  of  certain  kinds  of  pessaries  known  by  the 
names  of  their  inventors.  The  prevailing  idea  being  that  a  certain 
form  of  pessary  recommended  by  some  one  in  authority  will  answer 
for  all  cases,  a  slight  variation  in  size  being  all  that  is  necessary. 
This  is  certainly  a  great  mistake.  The  only  pessary  which  can  be 
of  service  is  one  that  is  correctly  adjusted  to  the  patient  who  is  to 
wear  it ;  not  a  ready-made  one  with  a  distinguished  name  and  repu- 
tation. An  abundant  experience,  so  far  as  seeing  and  treating  many 
cases  goes,  and  some  practical  knowledge  of  the  mechanical  art,  en- 
ables me  to  say,  that  no  two  cases  of  displacement  are  alike,  and, 
therefore,  each  one  must  be  fitted  with  a  pessary  of  the  special  form 
and  size  required.  This  really  simplifies  practice  greatly,  because  it 
enables  one  to  reject  the  vast  number  and  variety  of  ready-made 
pessaries  in  the  market,  and  to  choose  the  simj)lest  forms  and  adaj)t 
them  according  to  certain  principles  and  the  requirements  of  cases. 
In  the  books  there  is  no  end  to  the  number  of  instruments  com- 
mended, and  the  directions  to  introduce  and  remove  them  are  ample 
and  sufficient,  but  there  is  a  conspicuous  absence  of  any  definite  and 
useful  directions  regarding  the  manner  in  which  such  instruments 
are  to  be  fitted. 

In  the  simpler  cases  when  the  uterus  can  be  restored  to  its  posi- 
tion completely,  and  when  thus  restored  the  vaginal  walls  assume 
their  normal  shape,  the  pessary  is  easily  adapted.  The  length  of  the 
vagina  should  be  obtained  from  the  posterior  fornix  to  a  point  cor- 
responding to  the  upper  end  of  the  urethra,  and  the  width  of  the 
vagina  at  that  part  indicated  by  a  line  bisecting  the  center  of  the 
cervix  uteri  should  be  taken.  These  measurements  give  the  size  of 
the  pessary  required  in  length  and  width,  and  are  usually  taken 
through  a  Sims's  speculum,  with  the  patient  on  the  left  side. 

The  longitudinal  measurement  is  easily  obtained  by  a  sponge  and 
holder  (Fig.  154),  which  are  carried  up  by  the  side  of  the  cervix  to 
the  upper  termination  of  the  vagina,  and  there  marking,  with  the 
finger  resting  on  the  stem  of  the  sponge-holder,  the  point  opposite 
the  junction  of  the  bladder  and  the  urethra.  The  transverse  meas- 
urement may  be  taken  by  sight,  or,  if  the  eye  is  not  trained  suffi- 


RETROVERSION   OF  THE  UTERUS. 


525 


ciently  for  this,  by  a  pair  of  long  dressing-forceps  liaving  a  mark  on 
the  handles  the  same  distance  from  the  lock  as  the  point  of  the 
blades.  The  for- 
ceps are  passed  up 
and  the  blades  ex- 
panded until  they 
reach  the  lateral 
walls  of  the  vagina, 
and,  while  held  in 
this  position,  the 
measurement  is  ob- 
tained from  the  ex- 
tent of  separation 
of  the  handles.  The 
size  being  obtained, 
the  shape  next  de- 
mands attention. 
The  outlines  of  the 
Albert  Smith  pes- 
sary (Fig.  153),  are 
adapted  to  the  lat- 
eral vaginal  walls 
in  a  general  way, 
and  any  change  to 
suit  special  cases  is 
easily  made.  The  curves  for  the  antero-posterior  walls  are  slight 
modifications  of  the  ogee  curve  of  the  mechanic,  which  is  two  seg- 
ments of  a  circle  joined 
and  reversed.  This  shape 
may  be  taken  as  a  basis 
from  which  changes  of 
form  must  be  made  in 
every  instrument  used. 

The  guide  for  the  form 
of  these  curves  I  have  ob- 
tained in  this  way  :  I  first 
ascertain  by  touch  and  in- 
spection the  length  of  the 
invagination  of  the  cer- 
vix posteriorly,  and  then 
make  the  posterior  up- 
ward curve  of  the  pessary  a  little  short  of  the  extent  of  this  in- 


FiG.  154. — The  method  of  measuring  the  length  of  the  pes- 
sary ;  p,  retracted  perineal  body. 


anterior 
vaginal 

Wdll 


Fig.   155. — Diagram  of  pessary  in  situ  on  looking  at 
it  in  Sims's  position,  through  Sims's  speculum. 


326 


DISEASES   OF   WOMEK 


Fig.  156. — Slight  invagination  of  cervix  posteriorly 
with  suitable  pessary. 


vagination.  The  ante- 
rior downward  curve 
is  made  about  equal  to 
the  posterior,  subject 
to  shght  variations  to 
meet  special  cases. 

Figs.  156  and  157 
show  two  cases  dif- 
fering in  the  extent 
of  invagination,  with 
pessaries  adajjted  to 
them. 

These  rules  for  the 
adaptation  of  pessaries 
are  only  useful  as  a 
basis  to  start  from  ; 
each  case  requires  one 
deviation  or  more  from 
these  rules.      This  ne- 


cessitates a  material  for  a  pessary  which  is  easily  molded,  and 
this  is  happily  now  afforded  in  the  instrument  made  of  whale- 
bone and  fine  copper-wire,  and  then  covered  with  soft  rubber. 
This  kind  of  a  pessary  can  be  modeled  with  the  greatest  facility 
to  any  form. 

To  restate  briefly 
the  most  important 
points  in  the  manage- 
ment of  mechanical 
supports  in  the  treat- 
ment of  retroversion, 
I  would  say  that  my 
method  is  as  follows  : 
Sims's  position  and  his 
speculum  are  used  in 
replacing  the  uterus, 
and  when  it  is  restored 
the  measurements  are 
taken,  a  pessary  se- 
lected of  the  proper 
size  and  modeled  to 
suit  as  nearly  as  ])ossi-      t^      ,,„     t^    •,  i  •       ■    ,■       r        •        .   •    i 

,        •■'  .'  Jig.  157. — Dccidoil  iiivaginsition  of  cervix  posteriorly 

ble.       It  IS   then    intro-  litted  with  a  suitable  i)cssary. 


RETROVERSION   OF  THE   UTERUS.  327 

duced  and  careful  observations  made  to  see  if  it  fulfills  the  require- 
ments. If  it  does  not  it  is  removed,  altered,  and  reapplied,  care 
being  taken  never  to  Lave  tlie  instrument  large  enough  to  make 
general  pressure  on  the  vaginal  walls,  nor  of  such  shape  that  it  will 
make  undue  pressure  at  any  one  point. 

Where  possible,  I  prefer  to  introduce  and  remove  pessaries 
through  Sims's  speculum.  The  method  of  doing  this  is  very  sim- 
ple. In  the  introduction  the  perinseum  is  retracted,  and  the  pessary 
turned  up  on  the  edge  is  passed  beyond  the  vulva  and  then  turned 
half  round,  which  brings  it  into  position. 

It  is  usually  the  case  that,  in  the  treatment  of  retroversion,  the 
pessary  requires  to  be  changed  in  shape  quite  frequently  during  the 
first  two  or  three  weeks  that  it  is  in  use,  but  with  the  material  de- 
scribed this  is  easily  done.  When  the  utenis  is  well  in  place,  and 
the  vagina  no  longer  appears  to  be  undergoing  any  changes  from 
involution  and  contraction,  then  a  hard-rubber  pessary  is  made,  using 
the  soft  one,  which  has  been  made  to  answer  the  purpose,  as  a  model. 
The  hard  rubber,  of  course,  can  be  worn  a  much  longer  time  than 
the  soft,  and  is  much  more  agreeable  to  the  tissues. 

In  regard  to  the  modifications  to  be  made  in  pessaries,  to  suit 
cases  as  they  present  themselves,  all  that  is  necessary  will  be  said 
when  giving  the  histories  of  cases.  It  is  important,  however,  to 
keep  in  mind  what  has  been  said  in  regard  to  the  cases  in  which  the 
uterus  can  not  be  fully  restored  to  its  normal  position,  owing  to 
changes  in  the  posterior  vaginal  wall  and  the  uterine  ligaments.  In 
such  cases  the  restoration  to  the  normal  position  must  be  gradual, 
and  hence  the  use  of  the  pessary  is  to  keep  the  uterus  in  the  posi- 
tion in  which  it  is  placed  by  the  efforts  at  restoration,  and  by  the 
support  of  the  instrument  to  favor  a  tendency  toward  the  normal 
position  on  the  part  of  the  uterus.  In  the  management  of  such 
cases  the  posterior  part  of  the  pessary  should 
not  be  much  curved  upward,  if  at  all,  be- 
cause the  object  is  to  have  the  pessary  carry 
the  posterior  vaginal  wall  backward  behind 
and  below  the  uterus  to  support  the  body 
and  fundus,  while  the  cervix  resting  be- 
tween the  bars  of  the  pessary  is  unsupported 
and  free  to  sink  downward  and  backward  Fig.  1 58.— What  the  pessary 
as  the  body  of  the  uterus  rises.     Here  the 

principle  of  the  lever  acts  to  change  the  axis  of  the  uterus.  This 
is  shown  in  Figs.  159  and  160. 

The  lever  action  of  the  pessary  is  made  more  effective  by  the 


328 


DISEASES   OF   WOMEK 


post, 
wall 


ant. 


pressure  of  the  bladder  and  the  anterior  vaginal  wall  upon  the  ante- 
rior part  of  the  instrument,  which  inchnes  to  raise  the  posterior  j)art 

upward,  and  so  bring  the  pessa- 


ry into  a  more  oblique  position 
as  the  uterus  rises.  See  Fig„ 
159. 

The  pessary  being  wedge- 
shaped —  that  is,  narrower  in 
front  than  behind — is  held  up- 
ward by  the  contraction  of  the 
lower  portion  of  the  vagina, 
and  the  wedge-action  helps  the 
lever-action  of  the  pessary  to 
raise  the  uterus  and  throw  it  forward. 

In  regard  to  the  surgical  operations  employed  in  the  management 
of  retroversion,  I  may  say  that,  where  the  cervix  uteri  is  lacerated, 
it  should  be  restored,  and  also  that  the  pelvic  floor,  if  injured,  must 
be  operated  upon  in  order  to  care  retroversion.  In  fact,  very  little 
progress  can  be  made  in  the  treatment  of  retroversion,  unless  the 
pelvic  floor  and  uterus  are  normal  or  nearly  so. 

This  is  all  the  surgical  treatment  that  I  now  employ,  besides 
mechanical  support,  in  the  management  of  these  displacements. 


Fig 


159. — How  the  pessary  acts — shown  by 
the  arrows  in  the  diajiram. 


Alexander's  Operation. — In  recent  times,  Alex- 
ander, of  Liverpool,  has  devised  a  plan  for  the 
correction  of  uterine  displacements,  which  con- 
sists in  shortening  the  round  ligaments.  In  his 
presentation  of  the  subject  to  the  British  Gyne- 
cological Society,  he  said  that  the  operation  has 
now  been  performed  in  nearly  all  prominent 
cities  in  the  world,  and  by  most  operators  with 
more  uniform  success  than  generally  liefell  any 
new  operation.  He  never  found  any  difliculty  in 
finding  and  drawing  out  the  ligaments.  An  in- 
cision was  to  be  made  upward  and  outward  from 
the  pubic  spine,  in  the  direction  of  the  inguinal 
canal,  for  one  and  a  half  to  two  or  three  inches,  according  to  the 
fatness  of  the  subject.  A  considerable  thickness  of  subcutaneous  fat 
was  then  met  witli,  which  must  be  cut  through  by  subsequent  incis- 
ions, until  the  pearly,  glistening  tendon  of  the  external  oblique 
muscle  was  reached.  Midway  through  the  fatty  tissue  an  aponeu- 
rosis sometimes  appeared,  so  firm  and  smooth  that  it  might  cause 
the  operator  to  think  he  was  deep  enough,  l)ut  he  would  find  no  liga- 


1  CO. — Second  step  ; 
the  uterus  falls  into 
the  pessary. 


RETROVERSION   OF  THE   UTERUS. 


329 


ments  at  tliis  spot.  The  first  stage  of  tlie  operation  consisted  simply 
in  cutting  down  upon  tlie  tendon  of  the  external  oblique  muscle, 
until  it  appeared  clean  and  shining  at  the  bottom  of  the  wound. 


Fig.  161.- 


-The  knee-chest  position — air  enters  the  vulva,  and  distends  the  vagina,  and 
the  fundus  falls  in  the  direction  of  the  arrow. 


The  external  ring  was  then  found.  The  finger  passed  to  the  bottom 
of  the  wound  detected  the  spine  and  the  ring  outside.  Having  iso- 
lated the  external  wound,  and  tied  any  little  vessels,  the  next  step 
was  to  find  the  end  of  the  ligament.  By  everting  all  the  structures 
upward,  the  round  ligament  could  be  seen,  generally  at  the  lowest 
part,  and  with  the  white  easily  distinguished  genital  branch  of  the 
genito-crural  nerve  along  its  anterior  surface  and  close  to  it.  The 
ligament  at  this  stage  was  more  or  less  rounded  in  shape.  It  was  an 
easily  recognized  flesh-colored  structure.  When  the  ligament  was 
identified,  the  small  nerve  on  its  surface  was  to  be  cut  through 
without  dividing  any  of  the  ligament.  Then  gentle  traction  was  to 
be  made,  either  by  the  fingers  or  by  broad,  blunt-pointed  forceps. 
Bands  holding  it  to  neighboring  structures  were  cut  through  with 
scissors.  As  soon  as  it  began  to  peel  out,  it  was  left,  and  the  oppo- 
site side  begun.  The  final  stage  of  the  operation  consisted  in  placing 
the  uterus  in  position  by  the  sound,  and  pulling  out  the  ligaments 
until  they  were  felt  to  control  that  ]30sition.  A  curved  threaded 
needle,  with  fine  catgut,  was  used  to  stitch  each  ligament  to  both 
pillars  of  the  ring  and  the  external  abdominal  ring  was  closed  with- 
out strangulating  the  ligament  as  it  lay  between  them.  The  ends  of 
the  ligaments  were  now  cut  o£F,  and  the  remainder  stitched  into  the 
wound  by  means  of  the  sutures  that  closed  the  incision.  A  fine 
drainage-tul)e  was  inserted,  and  the  wound  washed  out  with  carbolic 
or  other  lotion  before  these  sutures  were  tied. 


330  DISEASES  OF  WOMEN. 

The  after-treatment  consisted  in  rest.  The  tubes  were  removed 
on  the  second  day,  when  the  wound  was  dressed.  The  mortality  of 
the  operation  might  be  set  down  as  nothing.  Three  deaths  had  oc- 
curred, but  they  were  due  to  preventable  causes.  As  mortality  did 
not  seriously  enter  into  any  consideration  of  the  results  of  this  opera- 
tion, the  real  question  at  issue  was  whether  it  fulfilled  the  intentions 
of  the  operator  and  satisfied  the  expectations  of  the  patient.  The 
operation  was  designed  to  correct  certain  uterine  displacements,  and 
these  alone.  Whether  the  discomfort  of  the  patient  would  be  there- 
by relieved,  entirely  depended  on  whether  or  not  the  symptoms  were 
due  to  the  displacement.  To  secure  success  the  operation  must  be 
properly  performed,  and  the  after-treatment  must  be  rational,  so 
that  no  strain  might  be  placed  on  the  ligaments  until  sound  union 
had  taken  place. 

Most  excellent  results  from  this  operation  have  been  reported  by 
many  surgeons.  I  have  not  practiced  it  very  often,  for  the  reason 
that  most  cases  are  curable  by  the  means  which  I  have  described, 
and  the  cases  that  are  incurable  by  such  means  are  also  incurable  by 
Alexander's  operation. 

In  estimating  the  merits  of  any  surgical  procedure  one  must 
always  bear  in  mind  its  disadvantages.  I  especially  call  attention  to 
this  subject  because  we  hear  enough  about  the  success  of  Alexander's 
operation  and  not  enough,  perhaps,  of  limitations  of  its  usefulness, 
if  we  rely  for  all  our  information  upon  the  strongest  advocates  of 
this  treatment  of  retro-displacements  of  the  uterus. 

During  my  investigations  of  retro-displacements  of  the  uterus  I 
found  the  round  ligaments  defective  in  some  cases.  This  led  me 
to  the  conclusion,  early  in  my  teaching  days,  that  atrophy  or  imper- 
fect development  of  this  ligament  was  a  frequent  cause  of  backward 
dislocations  of  the  uterus.  I  have  also  found  that  retroflexion  oc- 
curring among  nullipara  was  sometimes  accompanied  \vith  a  defect 
in  the  round  ligaments,  due,  I  presume,  to  a  lack  of  development. 
In  those  who  liad  acquired  retroversion  or  flexion,  I  presume,  the 
defect  was  due  to  atrophy. 

Recently  I  have  seen  two  cases  tliat  fully  illustrate  the  point  in 
question.  One  was  a  married  lady  about  thirty  years  of  age  who 
had  borne  two  children.  For  six  years  she  had  suffered  from  a 
retroflexion  of  the  uterus.  For  two  years  she  had  been  tormented 
with  a  painful  left  ovary.  She  had  been  treated  by  several  practi- 
tioners during  the  six  years  before  coming  to  me.  Finding  it  im- 
possible to  keep  the  uterus  in  place  by  any  support,  I  determined  at 
once  to  do  a  temporary  ventral  fixation  of  the  uterus.     In  my  bi- 


RETROVERSION  OF  THE   UTERUS.  331 

manual  examination  I  could  not  feel  the  round  ligaments,  and  on 
direct  inspection,  after  opening  the  abdomen,  no  trace  of  them  could 
be  found.  I  subsequently  removed  the  uterus  and  ovaries  at  niy 
clinic,  and  no  evidence  of  the  presence  of  round  ligaments  could  be 
found.  This  case  was  a  very  fortunate  one  for  investigation.  Be- 
tween the  folds  of  the  peritonaeum  where  this  ligament  should  be 
found  there  was  nothing  but  areolar  tissue.  These  two  cases  were 
much  the  same  as  others  that  I  have  examined  heretofore. 

I  have  consulted  with  my  associates  on  this  subject  and  have 
found  that  their  experiences  coincide  with  my  own.  I  have  asked 
Prof.  Browning,  Professor  of  Anatomy  at  the  Long  Island  College 
Hospital,  about  this  ligament,  and  he  has  told  me  that  he  finds  it  ill 
defined  in  some  of  his  subjects,  and  so  difficult  to  demonstrate  to 
his  classes  that  he  often  ignores  it  altogether.  Dr.  Lewis,  formerly 
Professor  of  Anatomy,  and  Dr.  F.  H.  Colton,  at  one  time  Demon- 
strator of  Anatom}^  give  me  the  same  account  of  their  observations 
reo-ardino;  this  liffaraent. 

I  have  observed  that  in  cases  of  retroversion  the  round  liga- 
ment is  at  first  stretched,  and  then  atrophy  begins  first  in  the  mid- 
dle of  the  ligament  and  becomes  complete  there,  while  the  uterine 
and  abdominal  ends  are  the  last  to  give  way.  This  explains  the  fact 
that  in  doing  Alexander's  operation  the  end  of  the  ligaments  is 
sometimes  found  in  the  inguinal  ring  fairly  well  developed,  while 
there  is  not  a  trace  of  it  left  in  the  abdominal  cavity  except  within 
an  inch  of  the  uterus,  where  a  few  fibers  may  or  may  not  be  found. 
Further  confirmation  of  this  opinion  has  been  obtained  in  having 
seen  expert  surgeons  of  large  experience  fail  to  find  the  round  liga- 
ment in  a  most  careful  dissection.  This,  I  presume,  is  a  reasonable 
explanation  of  the  failures  that  occasionally  come  to  light. 

There  is  still  another, objection  to  Alexander's  operation,  namely, 
that  hernia  follows  in  a  number  of  cases.  I  am  fully  satisfied  that, 
no  matter  how  carefully  one  may  do  an  Alexander's  operation,  the 
abdominal  wall  is  sometimes  weakened  at  the  point  where  the  incision 
is  made  and  the  patient  is  predisposed  to  hernia.  There  is  no 
trouble  immediately  after  the  operation,  but  in  after  years  when  the 
scar  tissue  is  absorbed  the  wall  of  the  abdomen  is  weakened  and 
hernia  is  likely  to  follow,  and  it  does  occur  in  some  cases.  I  have 
seen  three  patients  who  had  hernia  following  this  operation.  These 
cases  having  been  operated  upon  by  experts  and  having  such  results 
compel  me  to  believe  that  there  are  many  others,  for  it  is  hardly 
possible  that  all  the  cases  with  imperfect  results  should  have  come 
under  my  observation. 


332  DISEASES  OF  WOMEN. 

The  advocates  of  this  operation  claim  that  it  has  one  great  ad- 
vantage that  I  have  not  referred  to,  and  that  is,  the  short  time  re- 
quired to  cure  displacements  in  this  way.  I  have  never  found  that 
patients  saved  time  or  money  by  Alexander's  operation,  if  they 
were  curable  in  the  old  way.  In  treating  a  retroversion  the  patient 
is  under  observation  longer,  but  she  is  not  so  long  off  duty  as  in 
undergoing  Alexander's  operation,  and  hence  does  not  lose  as  much 
time.  To  the  surgeon  who  likes  to  operate  and  does  not  very  well 
understand  other  ways  of  treating  displacements,  this  operation  has 
a  wide  range  of  application,  and  is  popular  with  patients  who  like 
to  be  cured  quickly.  Still,  in  all  this  I  find  no  good  reason  for 
modifying  my  opinion  regarding  the  indication  for  the  employment 
of  Alexander's  operation. 

I  am  fully  satisfied  that  this  operation  is  valuable,  but  limited  in 
its  usefulness.  I  now  employ  it  in  one  class  of  cases,  namely,  retro- 
version or  retroflexion  accompanied  with  prolapsus  of  the  ovaries 
and  without  adhesions.  In  such  cases  the  uterus  can  be  restored  to 
its  normal  position,  but  can  not  be  held  there  by  mechanical  sup- 
port, owing  to  the  ovaries  being  in  the  way.  Such  cases  are  in- 
curable by  the  old  method  of  replacement  and  support,  but  are 
promptly  relieved  by  Alexander's  operation,  providing  the  round 
ligaments  are  all  right.  To  this  extent  I  indorse  this  operation  in 
the  cases  referred  to,  and  commend  it  as  a  most  valuable  procedure. 
It  has  been  brought  into  disfavor,  like  many  other  good  things,  by 
being:  overdone. 

Ventral  Fixation. — This  is  the  name  given  by  Sanger  to  the 
operation  of  fixing  the  fundus  uteri  to  the  abdominal  wall.  Kelly 
called  it  hysterorrhaphy,  and  later  has  used  the  term  ventral  suspen- 
sion, but  I  like  the  first  name  best,  as  it  is  most  comprehensive. 
The  indications  for  this  form  of  surgical  treatment  are  retroversion 
or  retroflexion  complicated  with  adhesions,  atrophy  at  the  junction 
of  the  body  and  cervix,  or  disease  of  the  ovaries  that  require 
ovariotomy.  The  operation  was  first  performed  by  Koeberle,  as 
follows  :  Having  had  occasion  to  remove  an  ovary  and  tumor,  he 
fixed  the  stump  in  the  abdominal  wound.  This  is  known  as  the 
indirect  method,  and  having  been  found  defective  has  been  aban- 
doned, I  believe,  in  favor  of  the  direct  method — that  is,  stitching  the 
uterus  directly  to  the  abdominal  wall.  A  number  of  different  ways 
of  doing  this  fixation  have  been  practiced  by  various  surgeons. 
Some  vivified  the  peritonaeum  at  the  points  to  be  united  by  scrap- 
ing ;  others  omitted  this.  Various  ways  of  introducing  the  sutures 
have  been  practiced.     Pozzi's  method  is  the  simplest,  and  as  efii- 


RETROVERSION  OP  THE  UTERUS. 


333 


cient  as  any.  lie  uses  a  continuous  suture,  which  he  passes  through 
the  muscular  layer  and  peritoneeuin  of  the  abdominal  wall  and 
through  the  peritonseum.  The  rest  of  the  abdominal  wall  is  closed 
in  the  usual  way.     He  uses  fine  silk.     I  prefer  chromicized  catgut. 

Operating  in  this  way  the  fixation  is  permanent,  at  least  it  re- 
mains for  a  long  time,  and  hence  I  have  looked  upon  this  procedure 
as  objectionable,  first,  because  it  is  an  abnormal  condition,  and  on 
theoretical  grounds  it  is  not  good  surgery  to  produce  one  morbid 
state  to  cure  another  if  it  can  be  avoided  ;  and,  in  the  second  place, 
this  fixation  of  an  organ  that  should  be  movable  quite  often  causes 
suffering  as  bad  as,  or  worse,  than  the  displacement. 

For  these  reasons  I  have  not  been  fully  satisfied  with  this  ven- 
tral fixation  described  in  the  books  and  practiced  by  surgeons  gen. 


Fig.  162. — Ventral  suspension.  The  uterus  is  swung  to  the  peritonaeum  of  the  anterior 
abdominal  wall  by  sutures  passed  under  the  utero-ovarian  ligaments.  To  the  right, 
beneath,  is  shown  the  incision,  with  one  stitch  ready  for  tying ;  above  this,  the  usual 
method  of  passing  the  stitches  through  the  peritonseum  of  the  fundus.  (From  photo- 
graphs of  a  cadaver.) 


erally.  I  have  therefore  made  the  fixations  so  delicate  that  in  time 
they  give  way  and  leave  the  uterus  free,  as  it  should  be.  The  way  of 
doing  this  operation  is  very  simple  in  principle,  hut  requires  consider- 
able skill  and  care  to  do  it  well.  The  object  is  to  fasten  the  utero- 
ovarian  ligaments  (at  their  junction  with  the  uterus)  to  the  inner  side 
of  the  abdominal  wall  with  a  chromicized  catgut  suture.  Adhesions 
are  formed  between  the  surfaces  thus  held  together  that  are  strong 
enough  to  hold  the  uterus  in  place  for  a  while,  but  will  give  way  in 
the  course  of  time.     During  the  period  of  fixation  the  natural  sup- 


334  DISEASES  OF   WOMEN. 

ports  of  the  utei'us  regain  their  strength  and  hold  the  organ  in  place 
after  the  artiiicial  fixation  has  given  way.  Much  care  is  necessary 
in  selecting  the  place  upon  the  peritoneal  surface  where  the  sutures 
should  be  introduced.  First,  one  should  measure  the  width  of  the 
uterus  at  the  point  where  the  sutures  are  to  be  introduced,  and  a 
little  more  than  half  of  that  represents  the  distance  that  each  suture 
should  be  from  the  median-line  incision  ;  then  the  distance  from  the 
pubic  bones  upward  to  where  the  lower  part  of  the  suture  should  be, 
about  the  thickness  of  the  uterus,  plus  three  quarters  of  an  inch  from 
the  pubes.  This  is  difficult  to  illustrate,  but  Fig.  162  may  help  to 
make  the  description  more  clear. 

The  uterus  should  be  supported  with  a  properly  adapted  pessary, 
and  the  cervix  kept  in  proper  position  until  union  is  completed.  In 
fact,  I  have  deemed  it  advisable  to  keep  the  pessary  in  position  for 
two  months,  in  order  to  prevent  a  recurrence  of  the  displacement 
when  the  ventral  fixation  gives  way.  With  this  kind  of  after-care 
my  cases  have  remained  well.  That  is  more  than  I  can  say  of  per- 
manent fixation,  for  all  the  cases  occurring  in  my  own  practice  and 
seen  in  the  practice  of  others  have  suffered  less  or  more  when  the 
uterus  remained  firmly  fixed  to  the  abdominal  wall. 

This  includes  all  the  surgical  treatment  of  retro-displacements  of 
the  uterus  that  I  have  found  necessary  to  relieve  curable  cases. 

Some  other  surgical  procedures  have  been  tried,  but  so  far  as  I 
can  discover  they  possess  no  advantages  over  the  operations  already 
described.  Neither  have  they  been  adopted  by  the  profession  gen- 
erally. Dr.  AVilliam  R.  Pryor  unites  the  uterus  to  the  bladder  by 
scarification  and  sutures.  I  quote  the  following  description  of  his 
operation  : 

"  The  patient  being  in  Trendelenburg's  position,  the  incision 
should  be  carried  well  down  to  the  pubic  articulation.  For  suture 
material  I  would  not  use  silkworm  gut  because  of  its  permanency, 
but  silk  or  catgut.  The  bladder  should  l)e  empty.  The  anterior 
surface  of  the  uterus  from  its  bladder  junction  to  the  level  of  the 
tubal  openings  should  be  scarified  in  the  middle  for  a  width  of  half 
an  inch.  Beginning  at  a  point  from  the  posterior  border  of  the  sym- 
physis not  greater  than  an  inch,  the  peritoneal  surface  of  the  bladder 
should  also  be  gently  scarified  for  a  space  equal  to  and  opposite  that 
on  the  uterus.  The  scarification  on  both  bladder  and  uterus  should 
be  so  done  as  to  cause  no  bleeding.  Even  though  the  dimensions  of 
the  bladder  be  greater  than  those  of  the  uterus,  so  as  to  necessarily 
leave  a  portion  of  the  bladder  undenuded,  it  matters  not.  But  as 
the  contracted  bladder  about  equals  the  uterus  in  length,  it  will  not 


RETROVERSION   OF   THE   UTERUS.  335 

often  happen  tliat  much  surface  on  the  bladder  will  be  left  unscari- 
fied.  The  suture  should  then  be  introduced  with  a  curved  needle 
without  cutting  edge.  Three  or  four  sutures  at  most  will  suffice. 
These  are  to  be  all  passed  under  the  bladder  peritonaeum  first,  and 
then  the  lowest  suture  under  the  uterine  serosa,  and  tied  to  one  side. 
The  same  with  the  other  sutures  in  turn.  About  half  an  inch  apart 
will  suffice  to  secure  accurate  coaptation.  The  sutures  are  tied  in  a 
flat  knot  and  the  ends  cut  short.  The  abdominal  wound  is  closed 
in  the  usual  way." 

Shortening  the  round  ligaments  within  the  peritoneal  cavity  has 
been  practiced  by  A.  Palmer  Dudley,  Polk,  Mann,  Wylie,  and  Bode. 
The  former  two  gentlemen  unite  the  round  ligaments  in  front  of  the 
uterus  by  first  vivifying  the  peritonaeum  and  then  introducing  one 
or  more  sutures.  One  very  objectionable  result  in  this  operation  is 
that  the  Fallopian  tube  is  bent  at  an  acute  angle  to  the  uterus  so  that 
it  is  liable  to  be  occluded  at  that  point. 

The  latter  surgeons  fold  the  round  ligaments  upon  themselves, 
and,  having  scraped  the  surface  brought  in  contact,  unite  them  with 
sutures  loosely  tied. 

Many  attempts  have  been  made  to  fix  the  uterus  by  the  way  of 
the  vagina  when  it  could  be  brought  into  position.  Some  of  these 
operations  I  shall  mention  here,  though  I  can  not  recommend  them 
as  having  any  advantages,  or  even  meeting  the  indications  as  well  as 
the  surgical  procedure  already  described. 

Metro-elytrorrhajyhy . — Byford  united  the  wall  of  the  cervix  uteri 
to  the  vaginal  wall  (in  front  or  behind,  according  to  the  displace- 
ment) by  vivifying  the  tissues  and  uniting  the  parts  with  sutures. 
According  to  Pozzi,  Doleris  practiced  pre-  or  retro-cervical  colpor- 
rhaphy,  but  I  have  not  discovered  that  the  results  were  satis- 
factory. 

Pelvic  Colpo-hysteropaxy.—Th.h  is  the  name  given  by  Pozzi  to 
Freund's  operation,  which  consists  in  opening  through  the  posterior 
vaginal  wall  into  the  sac  of  Douglas  and  suturing  the  supra-vaginal 
portion  of  the  cervix  to  the  peritonaeum  near  the  utero-sacral  liga- 
ments. 

Uniting  the  Bladder  and  Uterus  hy  the  Way  of  the  Vagina. — 
Mackenrodt  opens  the  vaginal  wall  in  front  of  the  uterus,  and,  after 
dissecting  up  the  peritonaeum  and  opening  it,  he  removes  a  portion 
and  unites  the  remainder  to  the  uterus  by  a  continuous  suture  run- 
ning from  one  tube  to  the  other.  The  bladder  wall  is  then  stitched 
to  the  uterus.  The  operation  is  the  same  in  principle  as  Dr.  W.  R. 
Pryor's,  already  described. 


336 


DISEASES  OF  WOMEN. 


Shortening  the  Round  Ligaments  through  the  Vagina. — "Winter 
and  Schauta  opened  into  the  peritoniieiim  through  the  vagina  be- 
tween the  uterus  and  vagina,  and  fastening  the  round  ligaments 
where  they  are  given  off  from  the  uterus  to  a  point  seven  or  nine 
centimetres  distant. 

AVortheim  called  this  operation  the  vaginal  Alexander  method. 
Yineberg  and  Polk  have  practiced  this  procedure  in  a  modified  form. 


BETROFLEXION   OF   THE   UTERUS. 

In  the  chapter  on  anteflexion  of  the  uterus  the  pathology  of 
flexions  generally  was  discussed,  and  the  classification  adopted  was 

that  flexion  was  a  de- 
formity and  not  a  sim- 
ple dislocation.  In 
fact,  a  very  broad  dis- 
tinction was  made  be- 
tween displacements 
and  flexions.  It  was 
observed  at  the  same 
time  that  retroflexion 
of  the  uterus  was  fre- 
quently— in  fact  in  the 
great  majority  of  cases 
— produced  as  a  result 
of  a  retroversion.  The 
uterus  first  becomes 
displaced  backward, 
and,  in  consequence  of 
the  deranged  forces 
acting  upon  the  uterus, 
it  becomes  bent  upon 
itself — that  is,  flexed  as  well  as  displaced.  Owing  to  this  close  asso- 
ciation of  retroversion  and  retroflexion,  and  the  fact  that  the  treat- 
ment of  l)otli  has  much  in  common,  I  have  placed  them  together. 

In  practice  I  have  made  out  two  degrees  of  retroflexion,  and  the 
flexion  is  confined  to  the  body,  the  cervix  maintaining  its  normal 
relations  to  the  vagina.  At  all  events,  the  cervix  is  never  bent 
backward. 

Pathology. — This  is  the  same  as  in  anteflexion,  so  far  as  the 
uterus  is  concerned.  There  is  a  want  of  snfiicient  tissue  at  the  junc- 
tion of  the  cervix  and  body  of  the  uterus,  the  point  where  the  flexion 


Fig.  163. — Fibroid  on  posterior  wall  of  uterus  simulating 
retroflexion. 


RETROFLEXION  OP  THE  UTERUS. 


337 


occurs.  In  the  majority  of  cases  the  cervix  and  upper  part  of  the 
vagina  are  farther  forward  in  the  pelvis  than  they  should  be,  and  the 
cervix  points  forward 
more  than  it  should, 
but  less  so  than  in  re- 
troversion. This  gives 
rise  to  a  little  short- 
ening of  the  anterior 
vaginal  wall,  or  else  an 
undue  invagination  of 
the  anterior  wall  of 
the  cervix. 

Symptomatology. — 
The  symptoms  present 
in  retroflexion  are  very 
much  the  same  as  those 
of  retroversion,  hence 
it  is  only  necessary 
here  to  note  some  few 
that  are  more  marked 
in  flexion  than  in  ver- 
sion. In  retroflexion 
the  menstrual  function  is  more  frequently  disturbed.  Dysmenor- 
rhcea  is  often  present,  and  although  the  pains  are  less  acute  than  in 
anteflexion,  they  are  far  more  marked  than  in  retroversion.  In 
many  of  those  having  retroflexion  the  menstrual  discharge  is  often 
quite  offensive ;  this  also  occurs  in  other  conditions,  but,  taken  in 
connection  with  other  signs  and  symptoms,  it  is  valuable  as  a  means 
of  diagnosis  in  this  affection. 

Physical  Signs. — The  points  of  difference  between  retroflexion 
and  retroversion  are,  as  observed  by  the  touch,  that  the  cervix  in 
flexion  does  not  point  toward  the  vulva  or  pubes,  but  is  nearly  in  its 
normal  position.  There  is  less  relaxation  of  structure  of  the  upper 
portion  of  the  vagina.  Behind  the  cervix  the  rounded  fundus  can 
be  felt  by  the  examining  finger  to  be  pointing  downward  and  back- 
ward, instead  of  directly  backward  as  in  retroversion.  Between  the 
cervix  in  the  vagina  and  the  fundus  uteri  the  angle  of  flexion  can 
be  felt.  All  this  can  be  made  out  by  the  vaginal  touch,  and  in 
favorable  cases  the  bimanual  examination  will  help  to  verify  the 
signs  obtained. 

When  the  abdominal  muscles  are  very  lax  and  the  vagina  long 
and  elastic  the  uterus  can  be  carried  upward  with  the  finger  which 
28 


Fig.  164. — Prolapsed  and  adherent  ovary  simulating 
retroflexion. 


338  DISEASES  OF  WOMEN. 

is  in  the  vagina,  and  brought  within  reach  of  the  hand  on  the  abdo- 
men— i.  e.,  the  uterus  can  be  grasped  and  examined  bimanually.  In 
that  case  the  deformity  of  the  uterus  can  be  clearly  made  out ;  but 
it  is  rare  that  this  is  practicable.  It  is  usually  impossible  to  reach 
the  anterior  wall  of  the  uterus  by  the  hand  placed  upon  the  abdomi- 
nal muscles.  In  the  great  majority  of  cases  I  have  been  obliged  to 
depend  upon  the  vaginal  touch  and  the  uterine  sound  to  make  a 
positive  diagnosis. 

The  two  conditions  which  I  have  found  simulating  the  physical 
signs  are  a  large  and  prolapsed  ovary  and  a  subperitoneal  fibroma 
on  the  posterior  wall  of  the  uterus.  These  are  shown  in  Figs.  163 
and  164. 

In  either  of  these  affections  the  touch  gives  the  signs  of  retro- 
flexion, and  it  is  only  by  using  the  sound  and  proving  that  the 
uterus  is  in  its  proper  position  and  form  that  they  can  be  distin- 
guished from  flexion.  While  the  sound  is  not  absolutely  necessary 
to  differentiate  between  retroflexion  and  such  conditions  as  those 
named,  I  find  that  it  gives  confidence  in  the  diagnosis  in  retroflexion 
to  pass  it  and  see  that  the  canal  runs  backward  and  is  not  distorted 
by  the  flexion. 

Sometimes  it  is  very  difiicult  to  pass  the  sound  around  the 
point  of  flexion,  and  in  order  to  do  so  it  may  be  necessary  to  raise 
the  fundus  and  also  the  cervix,  in  order  to  straighten  the  canal. 
When  the  uterus  is  very  tender,  much  care  should  be  exercised  in 
using  the  sound.  The  application  of  cocaine  is  useful  in  relieving 
the  hyperfesthesia. 

Causation. — Retroflexion  occurs  in  single  women,  and  also  in 
those  who  have  borne  children.  In  the  former  I  have  found  it 
much  more  frequently.  For  practical  purposes,  this  affection  might 
be  divided  as  regards  causation  into  two  forms,  congenital  and  ac- 
quired. From  the  history  of  those  cases  in  which  this  flexion  is 
found  in  early  life,  I  believe  that  it  is  brought  about  by  some 
lesion  of  development.  It  may  not  be,  strictly  speaking,  a  con- 
genital malformation.  It  is  more  likely  that  the  infantile  uterus 
becomes  retroverted  before  puberty,  and  then  when  secondary 
development  takes  place  the  increase  in  weight  of  the  body  and 
fundus  causes  dis^flacement  of  the  upper  part  of  the  uterus,  and 
the  cervix  being  held  in  place  by  the  resistant  vagina,  the  flexion 
is  produced.  This  is  the  only  explanation  of  the  production  of 
these  cases  at  puberty.  When  it  is  acquired  after  bearing  children, 
I  believe  that  retroversion  occurs  first,  and  if  the  cervix  meets  re- 
sistance from  the  anterior  vaginal  wall  and  bladder  in  front,  the 


RETROFLEXION   OP   THE   UTERUS. 


339 


flexion  is  produced.  If  the  uterus  is  made  to  bend  a  little  at  the 
point  of  flexion,  tlie  pressure  will  cause  atrophy  at  that  point,  and 
thereby  the  flexion  will  gradually  increase. 

It  is  possible  that  in  some  of  the  acquired  cases  there  is  some 
lesion  or  excess  of  involution  at  the  junction  of  the  body  and  cer- 
vix, and  the  walls  of  the  uterus  being  thus  weakened  at  that  point, 
permit  the  uterus  to  fall  over  backward. 

Prognosis. — In  acquired  cases,  and  uncomplicated,  appropriate 
treatment  will  usually  give  relief  if  persisted  in  long  enough.  In 
the  so-called  congenital  forms  there  will  be  found  cases  which  do 
not  yield  to  treatment.  Relief  from  the  most  distressing  symptoms 
may  be  obtained,  but  as  soon  as  the  mechanical  support  is  removed 
the  flexion  will  return.  The  resistance  of  some  cases  to  treatment 
I  have  found  due  to  a  rigid  state  of  the  posterior  wall  of  the  va- 
gina, which  prevents  the  use  of  a  pessary  which  would  extend  far 
enough  back  to  throw  the  fundus  forward.  In  such  cases  the  use 
of  a  pessary  often  aggravates  the  trouble. 

Treatment. — The  principles  of  treatment  in  retroflexion  are  the 
same  as  in  retroversion,  and  hence  need  not  be  discussed  here  fur- 
ther than  to  note  some  of  the  additional  means  necessary  in  flexion. 

To  restore  the  uterus  to  its  normal  form  and  position  it  is  often 
necessary  to  use  the  Elliott  adjuster,  and  to  repeat  its  use  a  number 
of  times  ;  then  a  pessary  should  be  employed  as  in  retroversion.  In 
adjusting  the  pessary  care  should  be  taken  not  to  curve  the  poste- 
rior bar  too  much,  but  to  shape  it  so  that  it  will  carry  the  posterior 
vaginal  wall  back  behind  the  body  and  fundus  so  as  to  support  both. 
This  can  be  made  clear,  perhaps,  by 
showing  the  effect  of  a  pessary  which 
is  not  of  proper  shape,  and  which  in- 
creases the  flexion  by  making  press- 
ure upward  in  place  of  backward 
(Fig.  165). 

Alexander's  operation  is  suggest- 
ed to  the  mind  by  those  cases  which 
do  not  yield  readily  to  treatment,  and 
I  presume  it  would  be  useful.  How- 
ever, the  only  cases  which  resist  the 
usual  treatment  are  those  in  which 
the  posterior  vaginal  wall  is  un- 
yielding and  the  uterus  can  not  be 
straightened  by  Elliott's  adjuster.  In  such  cases  there  is  reason  to 
suppose  that  the  uterus  is  fixed  in  its  malposition  by  some  old  cel- 


lOvcrcurved 

^v"''  pessary 


(after  pi- 
Barney) 


340 


DISEASES  OF  WOMEN. 


lulitis  or  peritonitis  ;  and,  if  so,  Alexander's  operation  would  not 

succeed. 

It  is  rather  rare  that  the  treatment  prescribed  fails.     In  obstinate 

cases,  in  which  the  frequent  straightening  of  the  uterus  does  not 

stimulate  tlie  growth  of  tissue  at  the 
point  of  flexion,  the  stem  pessary 
should  be  tried. 

The  canal  of  the  cervix  should 
be  dilated  sufficiently  to  admit  a 
'j  fair-sized  glass  or  hard-rubber  stem. 
The  stem  is  then  introduced  to  over- 
come the  flexion  and  keep  the  uterus 
straight,  and  the  pessary  is  used  to 
keep  the  stem  in  place.  The  same 
kind  of  stem  and  pessary  as  are  used 
in  the  treatment  of  anteflexion  are 
employed,  with  this  diflPerence,  that 

FiQ.  167.— Uterus  with  defective  walls;  the  pessary  is  adapted  to  keep  the 

the  supra-vaginal  portion  of  the  cer-  uterus   in  position  as  Well  aS  to  hold 
vix  18  elongated  (after  VVinckel).  .  ^ 

the  stem  in  place. 

To  recapitulate,  the  stem  corrects  the  flexion,  and  the  pessary 
corrects  the  retroversion  besides  keeping  the  stem  in  place. 

Atrophy  of  the  Uterine  Walls  at  the  Junction  of  the  Body  and  Cer- 
vix.— This  is  a  condition  which  causes  anteflexion  and  retroflexion, 
which  may  alternate  by  turning  the  body  of  the  uterus  backward 
or  forward.  I  have  found  it  in  those  who  have  borne  children,  and 
also  in  those  who  have  not. 

Pathology. — There  is  a  defect  in  the  middle  layer  of  the  ante- 
rior and  posterior  walls  of  the  uterus  at  the  internal  os  which  per- 
mits the  uterus  to  bend  forward  or  backward  with  equal  facility. 
Fig,  167  shows  the  appearance  of  such  a  uterus.  Such  cases  are 
rare,  and  have  a  clinical  history  very  much  the  same  as  anteflexion. 
I  can  give  the  best  description  of  the  affection  by  relating  the  his- 
tory of  a  well-marked  case. 


ILLUSTRATIVE    CASE. 


A  dressmaker,  single,  and  in  fair  general  health,  twenty-seven 
years  old,  came  under  my  care  in  the  hospital,  giving  the  following 
history :  She  began  to  menstruate  at  flfteen,  and  from  that  time 
until  she  entered  the  hospital  had  suffered  from  dysmenorrho^a. 
The  pain  at  her  periods  became  progressively  worse,  until  she  was 
entirely  unfitted  for  her  duties. 


RETROFLEXION  OF  THE  UTERUS.  341 

She  sought  relief  in  medicine,  but  only  large  doses  of  opium 
sufficed.  Becoming  wholly  useless,  she  entered  one  of  the  hospitals 
of  this  city,  and  remained  under  treatment  there  for  four  months. 
During  that  time  she  had  violent  hysterical  convulsions  at  her  men- 
strual periods,  and  deriving  no  benefit  from  treatment  was  dismissed 
as  incurable.  Upon  examination,  I  found  marked  anteflexion  of 
the  body  of  the  uterus,  and  owing  to  slight  stricture  of  the  internal 
OS  and  the  extreme  tenderness  of  the  uterus  the  sound  could  not 
be  passed  until  she  was  anaesthetized.  I  then  found  that  the  os 
internum  was  constricted.  I  incised  it  and  dilated  until  I  could 
pass  a  No.  9  English  sound.  At  the  same  time  I  used  Elliott's  ad- 
juster to  straighten  the  uterus,  and  carried  the  fundus  backward. 
This  was  accomplished  with  unusual  facility,  the  uterus  making  no 
resistance  to  bending  in  any  direction.  The  instrument  was  with- 
drawn, and  the  patient  placed  in  bed  to  rest ;  there  was  no  pain 
or  inflammation  following  this  treatment.  Three  days  afterward  I 
made  a  digital  examination,  and  found  the  uterus  retroflexed.  By 
using  again  the  Elliott  adjuster  I  was  able  to  change  the  retroflex- 
ion back  to  the  original  anteflexion,  which  remained  so  for  several 
days.  It  being  necessary  to  pass  the  sound  every  third  day  to  pre- 
vent the  recurrence  of  the  stricture  at  the  internal  os,  I  took  advan- 
tage of  the  opportunity  by  changing  the  flexion  a  number  of  times, 
and  found  that  whatever  position  I  placed  the  body  of  the  uterus  in 
it  would  remain  there. 

The  dilatation  of  the  os  internum  gave  the  patient  great  relief 
from  the  dysmenorrhoea.  The  usual  treatment  for  congestion  and 
hypersesthesia  was  continued,  and  the  canal  kept  dilated  by  the  use 
of  the  sounds.  A  stem  pessary  was  tried,  but  she  could  not  tolerate 
it  except  by  keeping  in  bed.  She  improved  so  much  in  two  months 
that  she  left  the  hospital,  and  only  returned  occasionally  as  an  out- 
patient. For  two  years  I  kept  her  under  observation,  and  although 
she  was  not  entirely  free  from  pain  she  was  able  to  make  her  living. 

In  this  case  I  feel  sure  that  the  trouble  originated  in  an  imper- 
fect growth  at  the  time  of  secondary  development. 

In  one  other  case,  of  which  I  have  full  notes,  the  flexion  came 
after  the  patient's  second  confinement,  and,  perhaps,  was  due  to  a 
derangement  of  involution. 


CHAPTER   XIX. 


ABUSE     OF     PESSAKIES. 


Injuries  to  the   Pelvic    Organs  Caused  by  the  Improper  Use  of 

Pessaries. — The  dangers  of  stem  pessaries  have  already  been  referred 
to  in  the  chapter  on  flexions,  so  far  as  their  liability  to  canse  acute 
inflammations  of  the  uterus,  pelvic  cellular  tissue,  and  peritonfeum. 
There  are  still  other  injuries  which  they  may  give  rise  to.  When 
the  stem  is  small  and  badly  adjusted  with  reference  to  the  character 
of  the  flexion,  the  point  of  the  instrument  may  become  imbedded  in 
the  wall  of  the  uterus,  or  the  lower  part  of  the  stem  may  divide  the 
posterior  wall  of  the  cervix.  Both  of  these  injuries  I  have  seen  in 
practice. 

In  one  case,  an  anteflexion  of  the  cervix,  a  small  stem  of  steel  with 
a  hard-rubber  disk  at  its  end  was  introduced  by  a  general  practi- 
tioner, and  left  in   place  for  three  months. 
^;    ^^"^   The  patient  soon  began  to  suffer  from  a 
)  purulent    discharge,    which    gradually    in- 
creased, and  there  was  much  pain,  greatly 
aggravated  by  walking.     When  I  saw  her 
the  relations  of  the  stem  and  uterus  were 
as  shown  in  Fig.  1C8.     After  the  removal 
of  the  stem,  the  cervix  presented  exactly 
the    same    appearance    as    that   seen  after 
Sims's  operation  for   flexion,    except   that 
there  was  more  thickening  of  the  edges  of 
the  wound  and  more  inflammation  than  I 
have  ever  before  seen  after  discision  of  the 
cervix  by  the  surgeon.     The  inflammation 
subsided  under  ordinary  treatment,  and  she 
was  at  least  none  the  worse  for  having  worn  the  stem. 

Another  patient  came  under  my  observation  while  wearing  a  stem 
pessary,  which  had  been  introduced  six  weeks  before  by  her  medical 


Fig.   ifi8. — Stem  of  pessary  ul- 
cerating through  cervix. 


a-12 


ABUSE   OF   PESSARIES. 


34-/ 


attendant.  Slie  bad  suffered  pain  and  tenderness  from  the  time  that 
the  stem  was  introduced,  and  for  a  week  before  she  came  under  my 
care  the  sutfering  was  so  great  that  she  was  obliged  to  stay  in  bed 
and  take  opium  fi-eely ;  she  had  also  a  purulent  discharge,  and  at 
times  bleeding.  The  stem  was  about  the  thickness  of  a  No.  9 
catheter.  It  was  made  of  hard  rubber,  and  was  held  in  place  by  a 
cup  pessary  in  the  vagina.  While  the  stem  was  still  in  place  (the 
vaginal  pessary  having  been  removed)  the  body  of  the  uterus  was 
found  to  be  markedly  antefiexed,  and  its  anterior  wall  near  the 
fundus  was  unusually  prominent,  as  if  it  contained  a  small  fibroid 
tumor. 

The  flexed  shape  of  the  uterus  led  me  to  suppose  that  the  stem 
must  be  curved,  but  on  removal  it  proved  to  be  straight. 

I  then  passed  with  some  difticulty,  owing  to  the  tenderness  of 
the  uterus,  a  much-curved  sound  into  the  cavity  of  the  uterus,  and 
then  after  straightening  the  sound,  it  was  passed  into  the  groove 
made  in  the  posterior  wall  by  the  stem.  One  might  sujDpose  that 
the  cavity  of  the  uterus  was  simply  dilated 
so  that  the  sound  could  be  curved  forward 
and  then  straightened  and  passed  along  the 
posterior  wall,  but  I  am  confident  that  such 
was  not  the  case.  The  posterior  wall  of  the 
body  was  flexed  forward  and  rested  upon 
the  anterior  wall  on  either  side,  and  the  sul- 
cus made  by  the  stem  was  in  the  center. 

Fig.  169  shows  the  conditions  as  they  ap- 
peared to  me  during  ray  examination. 

There  was  considerable  bleeding  after 
the  removal  of  the  stem,  and  the  uterus  be- 
came more  flexed  apparently  as  soon  as  the 
support  was  withdrawn.  There  was  relief 
from  the  acute  symptoms  and  inflammation  caused  by  the  instru- 
ment, but  the  dysmenorrhoea  was  worse  than  before. 

Atrophy  of  the  muscular  tissue  of  the  vaginal  walls  from  over- 
distention  by  pessaries  that  are  too  large  is  quite  frequently  seen. 
Practitioners  who  are  not  skilled  in  the  use  of  pessaries,  yet  never- 
theless use  them,  produce  this  injury  of  the  structures  of  the  vagina. 
The  same  unfortunate  results  are  effected  by  those  who  believe  in 
tlie  theory  that  in  order  to  keep  the  uterus  in  place,  in  retroversion, 
for  example,  it  is  necessary  to  use  a  pessary  large  enough  and  suf- 
ficiently curved  to  force  the  posterior  wall  of  the  vagina  far  up  in 
the  pelvis  above  its  normal  elevation. 


Fig.  169.— Stem   cutting 
through  body  of  uterus. 


344 


DISEASES   OF   WOMEN. 


The  following  case  will  illustrate  this  :  The  patient  had  children, 
and  was  said  to  have  had  a  displacement ;  probably  retroversion. 
She  was  treated  with  a  variety  of  pessaries,  so  she  told  me,  but  did 
not  get  well ;  when  she  came  to  me,  she  had  much  backache,  pelvic 
pain,  and  vaginal  leucorrhoea ;  she  was  then  wearing  a  pessary  nearly 
large  enough  to  till  the  pelvis,  and  much  curved  both  in  front  and 
behind. 

The  uterus  was  in  about  its  proper  place  in  the  pelvis,  but  the 
vagina  was  greatly  overdistended  and  its  walls  were  thin,  especially 
the  posterior  wall  behind  the  cervix.     On  removing  the  pessary,  a 

difficult  task  owing  to  its 
size,  the  vaginal  wall,  and 
the  rectal  wall  also,  I  think, 
fell  downward  and  formed 
a  rectocele  high  up. 

Fig.  170  will  give  an 
idea  of  the  state  of  the  parts 
as  they  appeared  to  the 
touch,  after  the  j^essary  was 
removed. 

The  part  of  the  thin  wall 
of  the  vagina  bulged  down- 
ward, and  felt  to  the  touch 
exactly  like  the  ordinary 
rectocele,  except  that  the 
protmding  mass  was  at  the 
upper  part  of  the  vagina  in- 
stead of  the  lower ;  when  seen  through  the  speculum  introduced 
about  an  inch  and  a  half,  this  was  confirmed  by  the  eye. 

The  first  impression  ol)tained  by  the  touch  was  that  of  a  portion 
of  intestine  distended  with  gas  lying  behind  and  below  the  cervix 
uteri.  The  patient  felt  a  little  more  distress,  strange  to  sa}',  after 
the  pessary  was  removed  ;  when  she  tried  to  walk  without  it,  she 
suffered  from  pain  and  tenesmus  very  severely.  This  I  have  found 
to  be  the  case  in  all  instances  of  overdistention  of  the  vagina; 
patients  suffer  witli  the  support,  and  for  a  few  days  suffer  more 
without  it. 

This  is  much  the  same  experience  as  ladies  have  who  can  not  go 
without  corsets,  and  the  tighter  they  lace  them  and  the  more  damage 
they  do,  the  more  they  miss  them  when  they  discontinue  their  use. 
This  patient  was  kept  rather  cpiiet  for  a  time,  and  astringent  in- 
jections were  used,  which,  after  a  long  time,  restored  the  vagina  more 


Fig.  1 70. — High  rectocele  due  to  improper  pes 
sary. 


ABUSE   OF   PESSARIES.  345 

nearly  to  its  normal  caliber.  There  remained  for  over  a  year,  when 
I  last  saw  her,  and  perhaps  ever  since,  a  sagging  of  the  upper  part 
of  the  posterior  vaginal  wall. 

Another  case,  somewhat  of  the  same  character,  came  to  me  from 
the  West.  She  was  forty,  and  single  ;  her  health  and  strength  had 
been  good  until  she  was  thirty-six  years  of  age,  when  she  began  to 
have  a  variety  of  nervous  symptoms  clearly  due  to  general  debility. 
She  was  treated  by  several  reputable  physicians,  but  not  recovering 
as  fast  as  she  desired,  she  consulted  still  another,  who  told  her  that 
she  had  falling  of  the  womb,  which  caused  all  her  troubles.  There 
was  not  a  symptom  that  pointed  to  any  disease  or  displacement  of 
the  sexual  organs,  but  a  Cutter  pessary  was  introduced  and  the 
patient  wore  it  about  two  years.  Her  general  health  improved  very 
little,  and  the  pessary  soon  caused  her  trouble ;  still  she  persisted  in 
wearing  it  because  the  doctor  said  she  must  do  so ;  her  condition  be- 
came so  wretched  that  she  came  East,  in  the  hope  of  gaining  relief. 

When  she  came  to  me  she  had  some  vaginitis  and  vulvitis 
caused  by  the  pessary,  but  the  uterus  was  perfectly  normal  in  every 
way.  The  Cutter  pessary  had  pushed  up  the  posterior  vaginal  wall 
far  beyond  the  cervix,  which  lay  on  one  side  of  the  instrument,  not 
between  the  bars  as  it  should  have  done. 

The  condition  of  the  posterior  vaginal  wall  at  the  upper  part  was 
about  the  same  as  in  the  case  just  related.  The  lower  part  of  the 
vagina  was  normal,  excepting  the  inflammation  caused  by  the  pes- 
sary. The  vulva  was  also  inflamed,  and  she  suffered  greatly  from 
this,  especially  in  taking  exercise.  This  patient  also  felt  the  want  of 
the  pessary  when  it  was  removed,  but  only  for  a  short  time.  She 
was  examined  seven  months  after  the  removal  of  the  instrument  and 
was  found  to  be  perfectly  well. 

Injury  of  the  Posterior  Vaginal  Wall  by  the  use  of  Pessaries  in 
Cases  of  Incurable  Retroversion. — This  case  illustrates  a  class  which, 
though  not  large,  deserves  notice.  In  retroversion  with  fixation  of 
the  uterus,  either  from  a  congenital  state  or  because  of  adhesions  or 
shortening  of  the  post-uterine  ligaments,  there  is  sometimes  a  slight 
mobility  of  the  uterus  which  admits  of  its  being  partly  restored. 
This  leads  the  practitioner  to  hope  that,  by  the  use  of  the  pessary, 
the  displacement  can  be  corrected.  The  result  is  that  the  posterior 
portion  of  the  pessary  makes  too  great  pressure  upon  the  vaginal 
wall  and  produces  inflammation  and  abrasion.  This  usually  causes 
a  free  vaginal  discharge  and  pain  enough  to  make  the  patient  seek 
relief  before  much  permanent  injury  is  done.  In  all  such  cases  pes- 
saries should  not  be  used  at  all,  but  if  one  is  employed  in  the  hope 


346  DISEASES  OF  WOMEN. 

of  doing  good,  it  should  be  abandoned  as  soon  as  it  causes  any  irri- 
tation. 

In  these  incurable  cases,  a  slight  relief  may  sometimes  be  given 
by  using  a  Peaslee's  ring,  or  a  Smith's  pessary  very  little  if  at  all 
curved  posteriorly.  Either  of  these  instruments  will  hold  the  uterus 
a  trifle  higher  in  the  pelvis,  and  this  will,  in  some  cases,  give  a  sense 
of  support  and  relief  to  tlie  patient. 

Overdistention  and  Atrophy  of  the  Anterior  Vaginal  Wall  from 
the  use  of  Anteversion  Pessaries. — This  condition  is  rarely  seen  ex- 
cept among  the  patients  of  those  who  look  upon  anteversion  as  a 
morbid  state  of  importance  whenever  it  occurs. 

In  order  to  raise  the  body  of  the  uterus  up  when  it  is  anteverted, 
it  is  necessary  to  elevate  the  anterior  vaginal  wall  far  beyond  its 
normal  position.  In  order  to  do  this,  the  instrument  must  make 
well-marked  pressure  upon  tlie  parts,  and,  if  this  is  continued,  the 
muscular  wall  becomes  atrophied  and  overdistended,  and  this  can 
be  carried  on  to  a  very  great  degree,  the  whole  length  of  the  vagi- 
nal wall  becoming  double  that  which  it  originally  was. 

When  the  pessary  is  removed  in  such  a  condition,  there  is  at 
once  observed  a  well-defined  and  large  prolapsus  of  the  vaginal  wall, 
and  if  the  instrument  is  left  out,  cystocele  will  soon  follow.  This 
is  the  rule,  but  the  final  results  depend  to  some  extent  upon  the 
length  of  time  that  the  pessary  has  been  worn. 

The  stretching  of  the  vaginal  walls  caused  by  pessaries  can  be 
overcome  by  removing  the  instrument,  and  prescribing  rest  and 
astringent  injections.  But  if  the  overdistention  has  been  kept  up 
long  enough  to  cause  atrophy  of  the  muscular  tissue,  the  injury  is 
pennanent  and  can  be  very  little  improved  by  treatment. 

There  is  also  danger  to  the  bladder  and  urethra  from  the  ante- 
version pessary.    The  following  case  Mall  show  how  this  comes  about : 

Frequent  Urination  associated  with  Slight  Anteversion  of  the  Blad- 
der.— The  lady  was  about  thirty,  and  had  a  child  seven  years  old. 
She  gradually  developed  a  pelvic  tenesmus  and  some  irritability  of 
the  bladder.  She  consulted  her  physician,  who  diagnosticated  ante- 
version of  the  uterus,  and  stated  that  the  disturbed  function  of  the 
bladder  was  due  to  the  malposition  of  the  uterus.  Thomas's  ante- 
version pessary  was  introduced  by  the  physician  in  charge  ;  this 
gave  the  patient  a  sense  of  support  which  was  agreeable,  but  more 
disturbance  of  the  bladder  M-as  caused.  The  physician  urged  the 
patient  to  wear  the  pessary,  telling  her  that  she  would  get  used  to 
it,  and  the  unfavorable  effects  would  pass  off  ;  but  this  proved  not 
to  be  the  fact.     The  patient  then  came  under  my  care,  having  worn 


AliUSE   OF   PESSARIES. 


?A7 


the  pessary  for  two  weeks ;  1  at  once  removed  it,  with  the  result  of 
giving  some  relief,  but  there  was  still  more  impatience  of  the  blad- 
der than  before  the  instrument  was  used  at  all.  The  true  state  of 
affairs  proved  to  be  that  the  patient  had  a  slight  catarrh  at  the  neck 
of  the  bladder,  not  due  to  the  malposition  of  the  uterus  at  all,  and 
the  pessary  only  increased  the  original  affection. 

In  proof  of  this,  the  symptoms  all  disappeared  when  the  disease 
of  the  bladder  was  removed,  and  without  changing  the  position  of 
the  uterus  in  the  least. 

Cup  Pessary  with  an  Extra- Vaginal  Support,  causing  Vulvitis  and 
TJlceration  of  the  Vagina. — All  the  pessaries  having  a  stem  attached 
to  a  band  around  the  body  have  given  trouble  when  worn  for  any 
length  of  time.  The  evil  caused  by  the  one  used  in  this  case,  is 
typical  of  most  of  them. 

The  patient  lived  in  the  country,  and,  while  suffering  from  pel- 
vic tenesmus,  called  in  a  physician  who  adjusted  a  Babcock's  uterine 
supporter  for  "  falling  of  the  womb."  She  was  directed  to  remove 
it  at  night  and  introduce  it 
in  the  morning.  For  a  short 
time  she  felt  some  relief, 
but  soon  began  to  suffer 
from  a  profuse  vaginal  dis- 
charge and  great  tenderness 
about  the  vulva.  The  suf- 
fering increased  until  she 
was  unable  to  walk,  and  the 
introduction  of  the  support- 
er gave  great  pain. 

When  I  examined  her  I 
found  the  relations  of  the 
uterus  and  supporter  as  rep- 
resented in  Fig.  171.  The 
uterus  was  retroverted  and 
the  cup  and  stem  were  situ-   ^"'-  171--Di8placement^causedbya  badly  adjusted 

ated  in  front  of  the  cervix 

and  held  the  anterior  vaginal  wall  high  above  its  normal  position. 
There  was  some  ulceration  of  the  vaginal  wall  and  general  vaginitis 
and  vulvitis. 

The  apparatus  was  removed,  vaginal  injections  of  borax  and 
water  employed,  and  in  a  short  time  the  inflammation  was  relieved. 
The  uterus  was  then  restored  to  its  normal  position,  and  retained 
there  with  a  pessary  such  as  I  use  in  such  cases,  and  she  did  very 


348  DISEASES  OF   WOMEN. 

well.  But  for  several  months  there  was  a  tendency  to  prolapsus 
of  the  anterior  vaginal  wall,  owing  to  the  overstretching  of  it  by 
her  former  supporter. 

The  Upper  Rim  of  a  Cup  Pessary  partially  imbedded  in  the  Vagina, 
around  the  Cervix  Uteri. — This  patient  had  a  prolapsus  uteri,  and 
the  physician  who  had  her  in  care  used  a  cup  and  stem  of  soft  rub- 
ber ;  the  cup  was  quite  a  large  one  and  its  edges  were  rather  sharp. 
I  think  it  was  called  the  Barrington  supporter.  She  was  much  re- 
lieved by  this  instrument,  being  able  to  do  her  duty  as  a  laundress, 
but  she  began  to  have  a  vaginal  discharge  and  occasional  bleeding, 
with  pain  and  tenderness.  I  saw  her  with  the  doctor  and  found  a 
ring  of  raw  tissue  in  the  vagina,  around  the  cervix  uteri,  correspond- 
ing to  the  size  and  shape  of  the  cup. 

The  uterus  was  large,  measuring  nearly  five  inches.  Evidently 
the  pressure  upon  the  instrument  was  more  than  the  tissues  of  the 
vagina  could  stand.  The  patient  rested  for  a  time  and  used  vagi- 
nal injections ;  the  parts  healed  promptly,  but  the  scar  tissue  re- 
mained tendei',  and  gave  way  under  the  pressure  of  the  instniment, 
whenever  she  wore  it  for  any  length  of  time. 

I  think  that  this  patient  conld  have  been  cured  by  rest  in  the 
recumbent  position  until  the  enlargement  of  the  uterus  and  I'elax- 
ation  of  the  vagina  had  been  overcome,  and  then  the  pelvic  floor 
restored.  But  she  could  not  give  the  time  to  this,  being  poor,  and 
obliged  to  work  to  live.  She  was  directed  to  wear  a  perineal  pad 
fastened  to  a  waist-l)elt,  and  slie  got  along  fairly  well  in  that  way. 

A  Pessary  imbedded  in  the  Posterior  Vaginal  Wall. — In  the  cur- 
rent literature  there  have  been  many  extraordinary  cases  recorded  of 
pessaries  having  passed  through  the  vaginal  walls  into  the  rectum 
and  bladder.  Some  of  these  cases  have  been  very  remarkable,  and 
have  been  recorded  as  matters  of  curiosity.  Little  has  been  said 
about  the  causes  of  such  accidents  or  how  to  manage  them. 

The  following  case  illustrates  the  most  common  forms  of  this  ac- 
cident :  The  patient  was  a  widow  who  had  borne  several  children, 
and  had  been  well  until  the  menopause,  vvhen  she  became  insane. 
At  the  outset  of  her  mental  derangement,  her  physician  suspected 
that  she  had  some  uterine  disease,  and,  on  investigating  the  case, 
found  the  uterus  larger  than  it  ought  to  be  and  retroverted.  He 
restored  the  organ  to  its  normal  position  and  introduced  a  pessary 
which  hold  it  there ;  the  instrument  was  well  adapted  and  answered 
the  purpose  well.  After  this  his  attention  was  wholly  directed  to 
her  mental  condition,  and  she  recovered  her  mind  in  about  one  year. 
The  pessary  was  forgotten  by  her    physician,   who    introduced  it 


ABUSE   OF  PESSARIES.  349 

while  she  was  in  the  asylum.  When  she  came  home,  or  soon  after, 
she  began  to  have  a  discharge  from  the  vagina  and  occasional  bleed- 
ing. I  then  was  called  to  examine  her,  and  found  all  that  portion 
of  the  pessary  which  rested  behind  the  cervix  uteri,  imbedded  in  the 
vaginal  wall.  The  tissues  to  the  extent  of  nearly  a  quarter  of  an 
inch  had  united  in  front  of  the  pessary  bar. 

Traction  was  made  upon  the  pessary  until  the  tissues  inclosing  it 
were  made  tense,  and  they  were  then  divided  down  to  the  instru- 
ment ;  there  was  much  bleeding,  but  the  parts  healed  well,  leaving  a 
large  scar  in  the  posterior  vaginal  wall. 

This  case  is  one  the  like  of  which  is  not  infrequently  seen  ;  they 
differ  from  most  of  those  already  mentioned,  in  the  important  fact 
that  they  occur  in  cases  in  which  the  instrument  is  well  adjusted  and 
answers  its  purpose  for  a  time,  causing  no  trouble  until  the  vagina 
begins  to  contract  during  the  final  involution  at  the  menopause. 

The  vagina  contracts  so  much  that  the  pessary,  which,  at  the 
time  of  its  introduction  was  small  enough  and  had  plenty  of  room, 
becomes  altogether  too  large  and  must  imbed  itself  in  the  vaginal 
walls.  I  have  seen  a  sufficient  number  of  these  cases  to  satisfy  my- 
self that  they  occur  in  the  practice  of  the  most  competent  gyne- 
cologists, sometimes,  perhaps,  from  neglect  in  giving  specific  direc- 
tions to  the  patient  to  report  from  time  to  time,  so  that  the  behavior 
of  the  pessary  may  be  watched,  but  more  often  from  the  fact  that 
the  patient  having  been  relieved  of  all  her  symptoms,  either  forgets 
the  pessary,  or  else  feels  secure  and  safe,  so  long  as  there  is  no  suf- 
fering which  she  can  not,  in  her  own  opinion,  attribute  to  the  meno- 
pause, the  time  when  there  is  the  greatest  danger  of  the  accident  in 
question. 

Pessary  entirely  imbedded  in  the  Vaginal  Walls,  except  about 
three  quarters  of  an  inch. — This  patient  came  to  me  when  she  was 
forty-six  years  old ;  she  was  still  menstruating,  but  irregularly,  and 
on  one  or  more  occasions  had  menorrhagia.  She  was  suffering  from 
a  prolapsus  of  the  uterus  which  caused  her  much  trouble  when  she 
was  on  her  feet.  I  restored  the  uterus,  and  used  an  instrument  to 
keep  it  in  place.  This  gave  her  relief  at  once,  and  she  was  able  to 
take  up  her  duties  as  in  times  past.  She  came  to  see  me  several 
times  and  I  made  some  applications  to  the  uterus  which  caused  a 
slight  endometritis.  I  directed  her  to  continue  her  visits  from  time 
to  time,  in  order  that  I  might  see  how  the  pessary  was  acting  ;  this 
she  did  not  do,  for  feeling  perfectly  well,  she  concluded  that  there 
was  no  need  of  further  treatment,  and  she  acted  accordingly.  Ten 
years  passed,  and  though  she  began  to  have  a  purulent  discharge 


350  DISEASES  OF  WOMEN. 

and  occasional  bleeding  from  the  vagina,  still  she  neglected  her 
self.  After  a  time  she  cahed  a  physician,  who  made  a  superhcial 
examination,  and  told  her  that  he  suspected  that  she  might  have  can- 
cer ;  he  advised  her  to  place  herself  again  under  my  care ;  this  she 
did,  and  I  found  the  vagina  almost  completely  closed.  On  the 
right  side  anteriorly,  I  fomid  a  small  portion  of  the  pessary  exposed, 
but  the  rest  was  imbedded  in  the  vaginal  walls  and  covered  over 
by  considerable  tissue. 

The  granular  and  highly-vascular  character  of  the  tissues  sug- 
gested that  the  doctors  suspicion  of  cancer  might  be  correct.  The 
pessary  could  be  felt  through  the  wall  of  the  rectum  which  appeared 
to  be  quite  thin  at  that  point. 

Passing  a  sound  into  the  bladder,  a  part  of  the  pessary  appeared 
to  be  encroaching  upon  it.  With  ditficulty  the  finger  could  be  passed 
between  the  free  portion  of  the  pessary  and  the  vaginal  wall  until 
it  reached  the  cervix  uteri,  which  was  normal.  The  pessary  had  to 
be  removed,  yet  the  task  appeared  to  be  a  ditficult  one.  There  was 
so  much  haemorrhage  caused  by  the  examination  that  I  dared  not 
divide  the  tissues  which  enclosed  the  pessary,  neither  did  I  feel  that 
I  could  with  safety  rapidly  and  forcibly  tear  the  instrument  out  of 
its  place,  fearing  that  I  might  do  damage  to  the  rectum  and  blad- 
der, I  finally  adopted  the  following  method  with  success :  Using  a 
Sims's  speculum,  I  seized  the  part  that  was  exposed  in  the  anterior 
part  of  the  vagina  with  a  very  strong  forceps,  and  with  a  small 
finger-saw  cut  out  the  section  within  reach.  I  then  laid  hold  of  an 
end  and  by  traction  caused  the  pessary  to  revolve  until  another  por- 
tion came  into  the  place  of  the  one  removed ;  this  was  sawed  off, 
and  piece  after  piece  was  taken  out  in  this  way  until  the  whole  was 
removed. 

The  sinns  was  washed  out  for  the  purpose  of  cleaning  it  and 
stopping  haeraorrlmge,  but  there  was  so  much  bleeding  that  I  had  to 
use  a  tampon  to  control  it. 

The  patient  did  quite  well,  and  beyond  a  marked  tliickening  of 
the  vaginal  walls,  has  now  no  trace  of  the  injiu-y. 

Since  my  experience  with  this  case,  I  have  seen  quite  a  number 
of  cases  of  imbedded  pessaries,  and  have  removed  them  in  the  way 
described.  Two  cases  I  have  in  mind  now  in  wliich  the  pessaries 
were  imbedded  in  the  posterior  vaginal  wall,  which  were  treated  by 
sawing  out  the  anterior  half  or  third  of  the  pessary,  and  then  by 
turning  the  remaining  portions  around  they  were  removed  without 
breaking  down  or  dividing  the  tissues  surrounding  it. 


CHAPTER   XX. 

HYPERTROPHY    OF    THE    CERVIX    UTERI. 

This  is  a  peculiar  and  rather  rare  affection.  It  differs  from  the 
enlargement  of  the  entire  uterus,  which  occurs  in  pregnancy  and  in 
some  of  the  inflammatory  affections.  The  hypertrophy  is  confined 
to  the  vaginal  portion  of  the  cervix,  and  is  distinct  from  the  enlarge- 
ment of  the  supra-vaginal  portion,  which  occurs  in  connection  with 
metritis,  subinvolution,  and  pregnancy. 

Pathology. — The  only  change  in  structure  of  the  cervix  is  in 
quantity.  The  length  of  the  cervix  is  increased,  which  is  the  main 
point  in  the  pathology.  Sometimes  it  is  thickened,  but  not  in  pro- 
portion to  the  elongation.  It  is  characterized  by  great  increase  in 
length  without  increase  in  the  diameter  of  the  cervix,  and  no 
changes  occur  in  the  composition  of  the  tissues.  This  is  a  true 
hypertrophy,  which  occurs  from  causes  wholly  different  from  the 
ordinary  conditions  which  produce  hypertrophy.  The  extent  of 
hypertrophy  differs  in  different  cases  ;  this  is  due,  to  some  extent, 
to  the  stage  of  progress  when  the  first  examination  is  made.  In 
some  cases  the  cervix  projects  from  the  vulva  one  or  more  inches, 
while  in  others  the  cervix  rests  just  behind  the  hymen  or  in  the 
vulva  (Fig.  165). 

The  cervix  is  generally  conical  and  the  os  externum  is  generally 
small,  as  it  should  be  in  the  virgin  cervix. 

It  occurs  in  the  unmarried  most  frequently,  but  occasionally  in 
those  who  are  married  but  sterile. 

Symptomatology. — The  symptoms  are  exactly  the  same  as  those 
due  to  prolapsus.  In  the  first  stage  there  is  pelvic  tenesmus,  and  a 
sense  of  overdistention  of  the  vagina.  The  presence  of  this  large 
cervix  causes  irritation  of  the  vagina  and  consequent  leucorrhoea. 
Owing  to  the  great  increase  in  the  length  of  the  uterus,  it  becomes 
doubled  up  in  the  pelvis,  and  this  often  affects  the  menstrual  func- 
tion, giving  rise  to  dysmenorrhoea.     In  the  last  stage  of  the  affec- 

351 


352 


DISEASES   OF   WOMEN. 


tion,  in  which  the  cervix  protrudes  from  the  vulva,  there  is  much 
discomfort ;  and  the  feehng  of  distention  causes  great  irritabiKtj  of 


Fig.  172. — Hypertrophy  of  the  cervix.    (-J.) 


the  general  nervous  system.     Excoriations  and  ulcerations  of  the 
mucous  membrane  are  produced. 

Physical  Signs. — The  bimanual  touch  reveals  the  fact  that 
while  the  fundus  uteri  is  at  its  normal  elevation,  the  cervix  is  either 
down  at  the  vulva  or  protruding  beyond  it.  At  the  same  time  the 
firmness  of  the  vaginal  walls,  occupying  their  normal  position,  shows 
the  great  length  of  the  extra-vaginal  part  of  the  cervix.  This  sign 
is  diagnostic  when  the  cervix  is  still  within  the  vulva,  but  when  the 
cervix  has  escaped  through  the  vulva  there  is  prolapsus  of  the  vagina 
which  obscures  the  signs  to  some  extent.  Emmet  claims  that  elon- 
gation from  prolapsus  of  the  uterus  has  been  mistaken  for  hyper- 
trophic elongation.  This  does  not  seem  possible  for  one  who  knows 
anything  al)Out  the  rudiments  of  gynecology.  By  restoring  the  pro- 
lapsed uterus,  any  little  elongation  which  may  have  come  from 
stretching  will  disappear,  while  no  change  of  position  will  make  any 
difference  of  length  in  hypertrophy.     The  use  of  the  sound  also 


HYPERTROPHY  OF  THE  CERVIX  UTERI. 


353 


helps  greatly  in  determining  the  extent  of  the   hypertrophic  elon- 
gation. 

Causation. — The  fact  that  this  affection  is  limited  to  the  virgin 
cervix  makes  it  appear  as  if  the  hypertrophy  might  be  due  to  neg- 
lected functions,  but  tlie  fact  is  that  its  cause  is  not  known. 

Prognosis. — The  hypertrophy  yields  to  surgical  treatment  very 
promptly.  All  the 
cases  that  I  have 
treated,  five  altogeth- 
er, have  been  com- 
pletely relieved  by 
amputation  of  the 
cervix. 

Treatment. — The 
removal  of  the  super- 
abundant intra-vagi- 
nal  portion  of  the 
cervix  by  amputa- 
tion, is  the  only  meth- 
od of  treatment  which 
gives  satisfaction. 

Several  methods 
of     operating      have 

been  employed,  such  as  the  circular  method,  made  with  the  knife  or 
scissors,  the  ecraseur.,  and  the  galvano-cautery  wire.     Originally,  in 
all  of  these  methods  the  stump 
was  left  to  heal  by  granula- 
tion.    J.  Marion  Sims  greatly 
improved    the   operation    by 
covering  the  stump  Avith  mu- 
cous membrane.     Simon  and 
Marckwald    made   a   double- 
flap    operation,    and    I    have 
adopted  a  modification  of  this 
method.     The  details  of  the         '^  -'   '.  /' 
operation,  as  I  perform  it,  are  Fig    175.  — Dia- 

as  follows :  _  Sjam^  reLvld^ 

A  rubber  cord  is  passed  around  the  cervix  and 
drawn  tight  enough  to  control  the  haemorrhage ;  the  ends  of  this 
cord  are  then  seized  with  a  fixation- fojceps,  which  keeps  them 
from  slipping,  and  also  holds  the  cervix  in  the  desired  position. 
The  cervix  is  divided  from  the  canal  outward  on  either  side  a£ 
24 


Fig.   lYS.— The  first  step;  splitting  the  cervix. 


Fig. 


174— The  double  flaps 
of  the  amputation. 


354 


DISEASES  OF  WOMEN. 


high  lip  as  tlie  amputation  is  to  he  made  (Fig.  173).     The  double 
flaps  are  then  made  with  the   scalpel   in   such   a  way  that  the  two 

short  flaps  are  on  the  in- 
side (Figs.  174  and  175). 
The  portions  removed  are 
wedge-shaped. 

Two  middle  sutures 
are  then  introduced  from 
the  cervical  mucous  mem- 
brane, or  short  flaps,  to 
the  outer  mucous  mem- 
brane, and  the  lateral  sut- 
ures are  used  in  the  same 
way  as  in  restoring  a  bilat- 
eral laceration.  Fig.  176 
shows  the  sutures  as  intro- 
duced, and  Fig.  177  shows 
them  when  tied. 

Before  tying  the  sut- 
ures the  rubber  cord 
should  be  loosened,  and  if 
there  are  any  vessels  that 
bleed  freely  they  should 
be  controlled.  Slight  ooz- 
ing is  controlled  complete- 
ly by  tying  the  sutures. 
There  are  two  things  which  have  been  brought  out  by  experi- 
ence, and  these  should  be  kept  in  mind.  The  flrst  is,  that  the  cer- 
vix after  amputation  retracts  or  shrinks, 
so  that  it  should  not  be  amputated  too 
high  up,  but  left  a  quarter  or  three 
eighths  of  an  inch  longer  than  it  should 
apparently  be.  It  will  be  found  short 
enough  two  or  three  months  after  the  op- 
eration. The  next  point  is,  that  the 
middle  and  outer  layers  retract  after  the 
operation  far  more  than  the  mucous 
membrane  of  the  cervix  ;  especially  is 
this  the  case  when  there  is  a  cervical 
endometritis  present.     In  several  of  my 

cases  I  found,  several  months  after  the  operation,  tliat  the  mucous 
membrane  protruded  from  the  os  externum,  and  had  to  be  clipjied 


Fig.  176. — The  sutures  in  place. 


Fig.  177. — The  sutures  tied. 


HYPERTROPHY   OF  THE   CERVIX  UTERI.  355 

off.  This  is  a  simple,  thing  to  do,  but  by  observing  the  directions 
this  item  of  after-treatment  will  not  be  required. 

The  after-treatment  is  the  same  as  that  employed  in  the  op- 
eration for  restoring  a  lacerated  cervix  uteri,  and  need  not  be  de- 
scribed here. 

In  a  certain  number  of  cases  I  have  noticed  that  the  outer  walls 
of  the  cervix  retract  more  than  the  mucous  membrane  after  this 
operation.  Immediately  after  the  parts  have  healed,  the  cervix  is 
quite  perfect,  but  in  a  few  months  the  mucous  membrane  protrudes 
beyond  the  muscular  wall.  This  is  more  likely  to  occur.  I  think, 
in  case  there  is  a  cervical  endometritis  accompanying  the  hyper- 
trophic elongation.  When  this  condition  of  protrusion  or  prolapsus 
of  the  cervical  mucous  membrane  is  found  subsequent  to  amputa- 
tion, the  easiest  and  quickest  way  is  to  draw  the  superabundant  tis- 
sue and  clip  it  off. 

Just  here  I  may  mention  that  hypertrophic  elongation  of  the 
anterior  half  of  the  cer\dx  occasionally  occurs  in  bilateral  laceration. 
When  this  elongation  is  very  great,  I  have  found  it  best  to  amputate 
the  redundant  part  as  a  preliminary  to  the  operation  for  the  lacera- 
tion. This  is  done  in  the  same  way  as  taking  off  a  finger  by  the 
flap  operation. 


CPIAPTEIi   XXI. 

FIBROMA    OF    THE    UTEKUS. 

This  fonn  of  neoplasm,  which  frequently  appears  in  the  wall  of 
the  uterus,  differs  materially  from  growths  generally.  In  many  re- 
spects it  is  unlike  any  other  neoplasm  in  genesis,  pathology,  and 
natural  history. 

Observations  made  in  recent  years  have  led  me  to  reject  the 
hitherto  accepted  opinion  that  fibroma  of  the  uterus  is  developed 
during  middle  life. 

I  am  now  convinced  that  it  is  congenital,  and  has  its  genesis  in 
lesions  of  arrangement  of  the  tissue  elements  of  the  middle  layer  of 
the  uterine  wall.  The  only  essential  difference  in  the  histological 
composition  of  the  middle  layer  of  the  wall  of  the  uterus  and  fibroma 
is  in  the  arrangement  of  the  tissues.  The  muscular  coat  of  the 
uterine  wall  is  arranged  in  three  layers,  longitudinal,  circular,  and 
oblirpie  ;  but  these  are  all  interlaced,  so  that  they  form  one  structure 
or  continuous  muscle. 

In  the  filjroid  neoplasm  the  fibers  are  arranged  in  circular  form 
around  a  given  center,  and  are  cut  off"  or  separated  from  the  wall  of 
the  uterus  by  a  thin  layer  of  areolar  tissue,  and  do  not  form  part  of 
the  uterine  wall.  It  may  be  said  that  this  tumor  is  in,  but  not  a 
part  of,  the  wall  of  the  uterus. 

Another  difference  between  the  structui-e  of  the  uterus  and  fibro- 
ma is,  that  in  the  developmental  changes  that  take  place  in  the 
uterus  during  gestation  the  rudimentary  muscular  cells  are  formed 
into  muscular  filaments,  while  the  tissue  elements  of  fibroma  in- 
crease in  quantity  but  do  not  change  in  form  or  character.  It  is 
more  of  the  nature  of  hyperplasia  than  degeneration. 

The  evidence  that  uterine  filiromata  have  their  origin  in  derange- 
ment of  embryonic  evolution  consists  in  their  having  been  found, 
in  a  rudimentary  state,  in  the  infantile  uterus  and  in  young  subjects, 
and  before  their  presence  had  been  announced  l)y  any  signs  or 
symptoms.  They  are  also  found  occasionally  with  other  congeni- 
tal lesions  of  development,  such  as  anteflexion  of  the  uterus. 

350 


FIBROMA   OF   THE    UTERUS. 


60( 


Figs.    178,    179. — Interstitial  fibro- 
mata (Winckel). 


Furthermore,  if  they  orig'inate  in  a  lesion  of  arrangement  of 
tissue  elements  (and  this,  I  believe,  is  a  fact),  this  must  of  necessity 
take  place  during  embryonic  life.  One 
can  understand  how  transformation  of 
cell  elements  and  the  development  of 
new  tissue  can  take  place  in  the  forma- 
tion of  tumors  ;  but  lesions  of  arrange- 
ment of  musculo-fibrous  tissue,  such  as 
occur  in  the  formation  of  uterine  fibro- 
mata, is  possible  only  during  develop- 
ment in  the  embryo. 

Fibroid,  fibrous  myoma,  fibromyo- 
ma,  and  hysteroma  are  the  names  that 
have  been  used  to  designate  this  varie- 
ty of  tumor.  I  prefer  the  term  fibroma,  believing  that  it  is  as  com- 
prehensive and  indicative  of  the  character  of  this  neoplasm  as  any. 
Fibromata  grow  usually  in  the  body  and  fundus  of  the  uterus,  but 
in  rare  cases  they  have  been  found  in  the  cervix.  All  of  these 
growths  originate  in  the  middle  coat  of  the  wall  of  the  uterus,  but 
the  direction  they  take  while  growing  varies  in  different  cases,  and 
this  has  led  to  a  very  clear  and  useful  classifi- 
cation of  fibromata.  AYhen  the  tumor  remains 
imbedded  in  the  middle  coat  of  the  wall  of  the 
uterus  it  is  called  interstitial  (Figs.  178  and 
179) ;  when  it  grows  toward  the  outside,  sub- 
peritoneal ;  and  when  it  grows  toward  the 
cavity  of  the  uterus,  submucous.  Figs.  178  to 
180  will  show  the  three  forms  classed  accord- 
ing to  location.  The  subperitoneal  variety 
might  well  be  divided  into  two  classes,  those 
that  are  situated  outside  of  the  broad  ligament 
and  those  that  are  within  its  folds. 
Though  very  little  has  been  said  in  books  about  the  fibromata 
which  grow  within  the  folds  of  the  broad  ligament,  the  history  of 
such  differs  so  much  from  the  ordinary  subperitoneal  variety  that  a 
special  notice  is  (juite  necessary.  Fibromata  situated  in  this  position, 
instead  of  becoming  pedunculated,  extend  outward  between  the  folds 
of  the  broad  ligament  and  drop  down  deep  into  the  pelvis.  It  is  not 
until  they  become  quite  large  that  they  extend  up  out  of  the  pelvis. 
Beine:  surrounded  by  the  folds  of  the  broad  ligament  thev  are  more 
firmly  fixed  in  the  pelvis  than  other  subperitoneal  tumors,  and  con- 
sequently cause  more  displacement  of  the  pelvic  organs.    The  uterus 


Fig.  180. — Subperitoneal 
and  submucous  fibro- 
mata (Winckel). 


358  DISEASES   OF  WOMEN. 

and  the  bladder  are  usually  pushed  far  over  to  the  opposite  side 
of  the  pelvis,  and  the  pressure  upon  the  ovaries  and  pelvic  nerves 
causes  the  most  pain  and  suffering  of  all  of  this  class  of  tumors. 
They  are  more  likely  to  cause  cellulitis  than  when  located  elsewhere. 
In  some  cases  the  tumor  drops  down  very  low  in  the  pelvis  behind 
all  the  pelvic  organs.  In  one  case,  unusually  large,  which  came 
under  my  care,  there  was  a  considerable  mass  behind  the  rectum 
which  extended  down  to  the  perinaeum.  It  appeared  to  be  a  part 
of  the  tumor,  but  I  presumed  that  it  nmst  be  something  else. 
Dr.  Thomas  Keith  saw  the  case,  and  pointed  out  that  the  tumor 
had  split  up  the  broad  ligament  in  its  growth,  and,  extending  down- 
ward beneath  the  peritonaeum,  necessarily  got  behind  the  rectum. 

The  location  of  fibromata  has  a  marked  influence  upon  the  his- 
tory and  treatment ;  the  classification  should  be  clearly  understood 
and  kept  in  mind  on  this  account.  Those  that  grow  toward  the 
inside  of  the  uterus  may  remain  broadly  attached  to  the  uterine 
wall,  or  they  may  become  pedunculated. 

They  may  be  single,  conglomerate,  or  multiple.  The  single 
tumor  consists  of  one  mass,  the  multiple  of  several  masses  situated 
apart  and  at  different  places  in  the  uterus,  and  the  conglomerate 
consists  of  a  number  of  masses  growing  close  together  and  sur- 
rounded by  one  capsule. 

Fibromata  vary  greatly  in  shape.  When  very  small  they  are 
usually  round,  but  as  they  grow  they  sometimes  become  irregular ; 
especially  is  this  true  of  the  conglomerate  variety. 

In  all  cases  the  tumor  is  in  a  sense  distinct  from  the  wall  of  the 
uterus.  The  tumor  is  in  the  uterine  wall,  but  not  a  part  of  it. 
There  is  in  almost  all  cases  a  clear  line  of  demarcation  between  the 
tumor  and  the  tissues  of  the  wall  of  the  uterus.  The  tissues  which 
surround  tlie  tumor  and  separate  it  from  the  neighboring  tissues  are 
chiefly  cellular,  and  form  what  is  called  the  capsule.  This,  after  all, 
is  only  a  separation  in  the  arrangement  of  the  tissues  of  the  uterine 
wall  and  tumor  which  shows  the  difference  between  the  two.  Were 
it  not  for  this  the  morbid  growth  would  be  very  much  like  a  cir- 
cumscribed hypertrophy  of  the  uterus.  As  it  is,  the  development, 
growth,  and  decay  of  fibroids  are  influenced  by  the  uterus,  from 
which  they  take  their  origin  and  nutrition,  and  are  governed  by  the 
same  laws. 

They  increase  in  size  during  pregnancy,  and  generally  diminish 
after  confinement,  and  after  the  menopause  they  disappear  with  the 
final  atrophy  of  the  uterus.  Even  in  the  absence  of  pregnancy  the 
growth  of  a  fibroma  resembles  the  normal  growth  of  a  pregnant 


FIBROMA  OF  THE  UTERUS.  359 

uterus,  in  the  respect  that  there  is  simply  an  increase  of  tissue  with- 
out change  of  structure.  The  I'ule  is  that  fibroids  do  not  increase 
by  growth  before  puberty,  and  they  usually  disappear  after  the 
menopause,  but  not  immediately  after  the  cessation  of  the  menstrual 
function.  Usually  the  menopause  is  postponed  in  cases  of  fibroma, 
the  patient  continuing  to  menstruate  until  fifty  years  and  over. 
Neither  does  the  decrease  in  the  tumor  begin  as  soon  as  the  menses 
stop  in  all  cases.  On  the  contrary,  the  organic  forces  which  main- 
tained the  menstrual  function  being  no  longer  called  for  are  devoted 
to  the  growth  of  the  fibroma,  and  this  growth  may  go  on  for  some 
time  after  the  menopause,  but  the  rule  is  that  in  time  the  process  of 
atrophy  begins,  and  the  tumor  diminishes  and  finally  disappears  alto- 
gether, or  returns  to  its  primitive  size. 

During  the  growth  of  these  tumors  they  frequently  change  their 
position  and  relations  to  the  uterus.  The  submucous  tumor  extends 
more  and  more  into  the  cavity  of  the  uterus.  This  change  in  posi- 
tion diminishes  the  area  of  connection  between  the  tumor  and  uterus. 
It  becomes  pedunculated,  and  in  this  condition  is  sometimes  de- 
scribed as  a  fibrous  polypus  of  the  uterus.  This  process  of  expul- 
sion of  the  tumor  from  the  uterus  may  go  on  until  separation  is  com- 
plete, the  tumor  being  expelled  as  is  an  ovum  in  miscarriage.  The 
same  changes  occur  in  the  reverse  direction  in  subperitoneal  fibro- 
mata. They  frequently  become  pedunculated,  and  it  has  happened 
that  they  have  become  detached  from  the  uterus  altogether.  When 
this  has  occurred  (which  has  not  been  often)  there  are  usually 
found  adhesions  of  the  tumor  to  the  abdominal  viscera,  and  a  vas- 
cular communication  between  the  tumor  and  the  parts  to  which  it 
has  become  attached  has  been  established.  Sometimes  such  adhe- 
sions occur  in  tumors  which  are  not  pedunculated,  though  it  is  a 
notable  fact  that  fibromata  are  the  least  liable  to  form  adhesions  of 
all  the  neoplasms. 

These  changes  of  fibromata  in  relation  to  the  uterus  are  aided, 
perhaps  effected  wholly,  by  muscular  contraction  of  the  uterus.  The 
process  is  in  the  nature  of  an  expulsion,  and  is  the  natural  way 
by  which  the  uterus  endeavors  to  free  itself  from  such  morbid 
growths. 

The  density  of  fibromata  differs  in  different  cases,  and  occasion- 
ally changes  in  the  same  case.  They  sometimes,  especially  if  large, 
become  soft  and  oedematous.  Sometimes  collections  of  serum,  blood, 
or  pus  are  found  in  the  tumor.  These  give  a  feeling  of  softness  and 
ill-defined  fluctuation.  When  this  condition  is  found  the  tumor  is 
usually  called  a  fibro-cyst,  but  there  is  a  difference  in  pathology  be- 


360  DISEASES  OF  WOMEN. 

tween  a  libro-cyst  and  a  fibroma  with  cjst-like  cavities  containing 
blood,  pus,  or  serum. 

I  have  seen  two  cases  of  fibroma  which  gave  the  pliysical  signs 
of  fibro-cysts.  They  were  both  large  submucous  fibroids,  and  situ- 
ated in  the  body  of  the  uterus,  leaving  the  fundus  free.  The  tumor 
closed  the  lower  part  of  the  cervix  uteri,  and  the  menstrual  fiuid  and 
secretions  of  the  mucous  membrane  accumulated  in  the  fundus  and 
upper  part  of  the  cavity  of  the  body,  and  formed  what  appeared  to 
be  a  fibro-cyst. 

After  the  menopause  these  fibromata  usualh^  diminish  or  remain 
stationary,  and  give  no  trouble  except  by  mechanical  action  upon 
neighboring  organs.  The  rule  is  that  they  either  disappear  or  at 
lea.st  give  no  further  trouble.  At  one  time  it  was  believed  that 
fibromata  were  capable  of  being  converted  into  cancer.  That  is  a 
mistake,  I  believe.  INfalignant  disease  may  appear  in  connection 
with  fibromata,  but  I  have  not  yet  found  any  reliable  evidence  that 
the  one  is  converted  into  the  other. 

Perhaps  fatty  transformation  is  the  usual  change  which  takes 
place ;  occasionally  calcareous  or  osseous  degeneration  occurs. 
Tumors  which  have  undergone  calcareous  degeneration  I  have  seen 
several  times,  but  I  have  not  seen  anything  like  true  osseous  forma- 
tions. Perhaps  it  would  express  the  facts  better  in  most  cases  to 
call  this  material  bone-like  rather  than  to  convey  the  idea  that  it  is 
true  bone.  These  changes  or  degenerations  in  fibromata  usually  are 
conservative.  First  the  tumor  stops  growing,  and  then  undergoes 
atrophy,  or  is  transformed  into  osseous-like  or  calcareous  material, 
but  in  either  case  the  rule  is  that  the  patient  is  relieved.  In  some 
rare  cases  the  tissues  soften  and  suppurate,  and  septicsemia  is  pro- 
duced.    One  such  case  occurred  in  my  practice  and  i^roved  fatal. 

CHANGES   IN   THE  UTERUS   FROM   THE   EFFECTS   OF 
FIBROMATA. 

The  pathological  changes  which  take  place  in  the  uterus  dur- 
ing the  presence  of  a  fibroma  are  of  much  interest.  It  becomes 
enlarged  in  all  cases,  but  most  of  all  in  the  submucous  and  inter- 
stitial varieties,  less  so  in  the  subperitoneal,  and  least  in  the 
pedunculated  subperitoneal.  Cei-tain  changes  in  the  mucous  mem- 
brane of  the  uterus  usually  occur.  There  are,  in  many  cases,  poly- 
poid growths  developed,  and  endometritis  is  almost  always  present. 

In  regard  to  the  changes  in  tlie  mucous  membrane  which  occur 
in  connection  with  fibroma,  Dr.  Wyder,  of  Berlin,  makes  the  follow- 
ing statement : 


FIBROMA   OF   THE   UTERUS.  301 

"  Fibromyomas  are  said  to  be  likely  to  give  rise  to  malignant 
diseases  of  the  mucous  membrane. .  Martin  has  formerly  maintained 
that  these  conditions  furnish  an  indication  for  total  extirpation. 
The  writer,  having  examined  a  number  of  cases,  does  not  share  this 
view. 

"  "With  subperitoneal  myomas  the  mucous  membrane  was  found 
much  thickened  ;  the  most  important  alteration  was  a  very  perfect 
glandular  endometritis.  In  one  case  adenomatous  J^olypi  were 
present ;  in  another,  on  one  side  glandular,  on  the  opposite  side 
interstitial,  endometritis. 

"  For  interstitial  myomas  three  groups  must  be  formed  : 

"  1.  Where  the  tumors  are  separated  from  the  uterine  cavity  by 
a  wall  one  half  to  one  centimetre  thick. 

"  2.  Where  the  tumor  is  beneath  the  mucous  membrane  but  does 
not  project. 

"  3.  AVhere  the  tumor  projects  largely  into  the  uterine  cavity. 

"  Of  seven  cases  in  the  first  group,  in  one  no  alterations  were 
found  ;  in  two,  glandular  endometritis  (mucosa  four  to  ten  milli- 
metres thick) ;  in  three,  interstitial  endometritis.  In  most  cases  the 
vessels  were  very  numerous  and  their  walls  very  thick. 

"  In  the  second  group,  the  deeper  layers  of  the  mucous  mem- 
brane were  completely  transformed  into  connective-tissue  trabeculse ; 
at  the  surface  was  a  greatly  dilated  capillary  network  with  thick- 
walled  vessels. 

"  In  the  third  group,  interstitial  endometritis  was  found. 

"  The  thicker  the  wall  separating  the  tumor  from  the  uterine 
cavity  the  more  is  the  glandular  structure  developed  (glandular  en- 
dometritis) ;  the  closer  the  tumor  approaches  the  mucous  membrane 
the  more  pronounced  becomes  the  connective-tissue  character  of  the 
proliferation  in  the  mucosa  (interstitial  endometritis).  We  then 
find  the  mucosa  on  one  side  atrophied  into  connective  tissue,  and  on 
the  other  in  a  state  of  glandular  proliferation.  As  regards  the 
source  of  the  haemorrhages,  it  should  be  remarked  that  no  vascular 
changes  are  to  be  expected  in  subperitoneal  tumors.  It  was  found 
that  where  glandular  endometritis  was  alone  present  no  haemor- 
rhages had  gone  before.  In  the  case  of  interstitial  tumors  associated 
with  glandular  endometritis  exclusively  there  was  likewise  no  pre- 
ceding haemorrhage.  It  was  present  only  with  interstitial  en- 
dometritis. Therefore  haemorrhage  will  not  take  place  where  the 
interglandular  tissue  is  quite  intact ;  but  it  will  occur  where  both 
structures  proliferate  equally  (endometritis  fungosa),  or  where  one 
or  the  other  form  develops  predominantly,  or  where  glandular  en- 


362  DISEASES  OF   WOMEN. 

dometritis  exists  on  one  side  and  interstitial  endometritis  on  the 
other.  Compression  of  the  numerous  vessels  causes  venous  con- 
gestion ;  hgemorrhage  will  set  in,  especially  when  glands  and  tissue 
have  proliferated  equally.  The  glands  exert  no  influence  on  the 
under  surface ;  their  character  is  usually  benign.  The  border  line 
between  mucosa  and  muscle  is  intact.  Endometritis  glandularis  is 
of  a  benign  nature." 

These  pathological  changes  in  the  mucous  membrane  and  the 
increase  in  its  extent  by  the  great  enlargement  of  the  uterus  cause  a 
marked  increase  in  the  vascularity.  To  this  state  is  due  the  menor- 
rhagia  and  hemorrhage  which  are  so  generally  present  in  cases  of 
fibromata.  Deformity  of  the  uterus  is  produced  in  many  cases,  but 
in  some  even  large  tumors  the  uterus  presents  the  form  present  in 
pregnancy.  It  is  simply  enlarged  but  not  changed  in  form.  There 
is  often  displacement  of  the  uterus,  especially  in  the  interstitial  and 
subperitoneal  varieties.  The  tumor  either  drags  the  uterus  toward 
the  side  upon  which  it  is  located,  if  it  is  small,  or  pushes  the  uterus 
in  the  other  direction,  if  the  growth  is  large. 

The  cervix  uteri  may  be  disturbed  in  many  ways.  It  is  some- 
times greatly  elongated  and  far  out  of  its  normal  position.  Many 
times  it  is  spread  out  on  the  tumor  so  that  it  appears  to  be  a  part  of 
it.  The  canal  of  the  cervix  is  often  tortuous  and  its  caliber  lessened. 
Pressure  of  the  uterus  upon  surrounding  organs  may  cause  derange- 
ment of  function.  These  effects  depend  upon  the  size  and  location 
of  the  tumor,  with  reference  to  the  degree  of  the  derangement. 
When  the  tumor  is  still  small  enough  to  remain  in  the  pelvic  cavity 
and  make  pressure  to  a  limited  extent  only,  the  symptoms  produced 
resemble  those  caused  by  uterine  displacements  and  small  ovarian 
cysts.  The  rectum  may  be  pressed  upon  and  its  function  perverted. 
The  bladder  uiay  suffer  from  pressure  which  may  prevent  it  from 
distending,  or  it  may  be  rendered  irritable  and  tender.  In  some 
cases  the  pressure  may  become  so  great  that  the  function  of  the 
bladder  and  rectum  may  suffer,  and  even  the  ureters  themselves 
may  be  affected  in  the  same  way.  I  have  seen  several  cases — three 
in  all,  I  think — where  the  ureters  were  obstructed  from  the  pressure 
of  fibromata,  and  the  kidneys  were  affected  in  consecpience.  The 
pressure  may  become  so  great  that  the  function  of  the  rectum  or 
bladder  l)ecomes  arrested,  and  infiammation  of  the  cellular  tissue 
or  peritomeum  may  occur  and  prove  fatal.  I  have  repeatedly 
seen  slight  attacks  of  pelvic  infiammation  caused  by  pressure  of 
fibromata;  one  case  ])rove(l  fatal  from  pelvic  inflammation  and  rectal 
obstruction.     I  saw  the  patient  first  when  she  began  to  have  infiani- 


FIBROMA   OF   THE   UTERUS.  303 

mation,  and  I  found  the  tumor  impacted  in  the  pelvis  and  it  could 
not  be  dislodged  by  any  means.  The  inflammation  progressed, 
and  the  obstruction  of  the  rectum  became  complete  by  the 
addition  to  the  tumor  of  the  products  of  the  inflammation.  In 
most  cases  the  tumor  can  be  raised  up  out  of  the  pelvis  when  it  be- 
comes large  enough  to  give  much  trouble.  The  pressure  may  be 
upon  the  pelvic  nerves  so  as  to  cause  very  great  pain.  When 
fibromata  escape  from  the  pelvic  to  the  abdominal  cavity  they  do 
not  cause  so  much  trouble  unless  they  become  very  large.  They 
may  cause  peritonitis  and  intestinal  obstruction,  but  that  is  rare. 
They  were  formerly  supposed  to  cause  ascites,  because  fluid  in  the 
peritoneal  cavity  was  found  in  a  certain  proportion  of  cases.  Keith 
believes  that  this  fluid  is  a  transudation  from  the  tumor  rather  than 
from  the  peritonaeum,  as  in  ordinary  ascites.  The  quantity  of  the 
fluid  is  seldom  sutiicient  to  cause  much  distress. 

Symjytoriiatology. — The  symptoms  of  uterine  fibromata  are  natu- 
rally of  three  kinds  :  First,  those  manifested  by  the  general  system, 
which  are  also  called  constitutional  or  remote ;  second,  those  which 
originate  in  the  uterus  itself ;  and,  third,  those  that  are  produced  by 
the  pressure  of  the  tumor  upon  neighboring  organs.  The  severity 
of  the  remote  symptoms  depends  upon  the  size  and  location  of  the 
tumor.  There  are  a  great  many  patients  who  do  not  suffer  in  general 
health  from  fibromata  of  the  uterus  until  the  growth  has  advanced 
to  a  considerable  size.  Sooner  or  later,  according  to  the  extent  of 
disturbance  which  the  growth  causes,  the  general  health  becomes 
impaired.  The  patient  becomes  anaemic  and  is  generally  debilitated, 
because  of  either  the  loss  of  blood  or  deranged  nutrition,  or  both. 
These  symptoms  are  not  by  any  means  diagnostic,  but  may  come 
from  a  variety  of  affections.  In  the  most  marked  cases,  when  the 
patient  is  extremely  anaemic,  the  skin  becomes  slightly  bronzed,  and 
gives  to  the  patient  the  appearance  of  having  malignant  disease. 
The  symptoms  which  are  manifested  by  the  uterus  are  pain  and 
haemorrhage.  The  pain  is  not  always  pronounced,  in  some  cases  it 
is  not  at  all  persistent.  It  is  irregular,  spasmodic  in  character,  and 
is  most  marked  when  the  tumor  is  submucous,  and  least  so  in  the 
interstitial  variety.  The  haemorrhage  is  the  most  prominent  symp- 
tom of  all.  It  usually  comes  on  periodically,  and  is  therefore  in 
some  cases  a  menorrhagia.  Menstruation  is  too  free,  and  lasts  too 
long  and  recurs  too  often.  Bleeding  may  come  at  any  time,  there 
being  no  regularity  whatever  in  some  cases.  This  sj'raptom  is  so 
constantly  present,  that  Dr.  J.  Mathews  Duncan  called  fibroma  the 
bleeding  disease  of  the  uterus. 


364  DISEASES  OF   WOMEN. 

This  name  is  well  deserved,  for  certainly  no  other  affection 
gives  rise  to  so  nnich  haemorrhage  of  the  uterus  as  does  this.  The 
size  of  the  tumor  does  not  intiueuce  the  severity  of  the  bleeding. 
In  some  small  tumors  the  bleeding  is  greater  than  in  others  of  mon- 
strous size.  It  is  the  location  of  the  tumor  and  the  complications, 
such  as  endometritis  in  various  forms,  which  determine  the  ha^mor- 
rhagic  symptoms.  It  is  greatest  in  the  submucous,  less  in  the 
interstitial,  and  least  in  the  subperitoneal,  as  a  general  rule.  The 
submucous  pedunculated  variety  is  the  most  liable  of  all  to  cause 
bleeding.  A  very  small  tumor  of  this  kind  may  cause  the  most 
persistent  and  exhausting  lui^morrhage.  The  symptoms  produced 
by  the  pressure  of  the  tumor  upon  neighboring  organs  are  generally 
most  marked  when  the  tumor  occupies  the  pelvic  cavity  ;  then  the 
pressure  upon  the  bladder  and  rectum  causes  irritation  and  func- 
tional obstruction  of  these  organs,  and  less  or  more  pelvic  tenesmus 
of  a  general  character.  The  elfect  upon  the  bladdei-  is  to  render 
urination  very  frequent  and  sometimes  difficult  or  impossible.  I 
have  seen  three  cases  in  which  there  was  retention  of  urine.  The 
tumor  was  pear-shaped  in  all  of  them,  and  large  enough  to  extend 
above  the  brim  of  the  pelvis.  The  urethra  and  bladder  were  car- 
ried upward,  so  that  the  urethra  was  caught  between  the  tumor  and 
the  piibic  bones  and  compressed.  Urination  in  these  cases  was  for 
a  time  difficult,  and  then  retention  came.  All  voluntary  efforts 
to  evacuate  the  bladder  only  made  matters  worse,  by  forcing  the 
tumor  downward  and  wedging  it  into  the  superior  strait.  Ilelief 
was  given  first  by  the  catheter,  and  then  by  pushing  the  tumor  up- 
ward, the  patient  being  placed  in  a  knee-chest  position.  Pressure 
upon  the  pelvic  nerves  and  ovaries  often  causes  much  pain.  Pain 
in  the  back  and  limbs,  which  is  often  present,  no  doubt  comes  from 
the  same  cause. 

Pressure  upon  the  ui-eters  may  cause  obstruction  and  hydro- 
nephrosis, and  all  the  unfortunate  results  to  the  kidney  which  must 
follow.  In  such  cases  there  is  at  first  ])ain  in  the  region  of  the 
ureters,  and  subsequently  the  symptoms  of  renal  disease  appear. 
Fibromata  large  enough  to  occupy  the  cavity  of  the  al)domen  give 
very  little  trouble,  as  a  rule.  A^ery  large  tumors  interfere  with  fi-ee 
res])iration,  and  the  action  of  the  stomach  and  bowels  to  some  ex- 
tent. The  ascites  which  sometimes  accom])anies  fibromata  of  the 
uterus  was  supposed  to  be  due  to  irritation  of  the  pcritomeum.  It 
is  more  likely  that  it  is  a  transudation  from  the  tumor  itself,  as 
already  stated.  This  is  sugi^ested  by  the  fact  that  hydro-peritonaeum 
is  usually  found  in  connection  with  oedematous  tumors. 


FIBROMA   OF   THE   UTERUS. 


365 


Figs.  181  and  182. — Enlargement  due  to  sub- 
involution compared  with  that  from  growth 
of  a  fibroma  (after  Winckel). 


Physical  Signs. — The  positive  signs  of  iibroiiia  are  tlie  increase 
in  size,  change  in  form  and  consistence  of  the  uterus,  and  the  dis- 
placement or  distortion  of  the  canal,  as  related  to  the  body  of  the 
uterus.  The  touch  discovers  the  fact  that  the  uterus  is  enlarged, 
apparently,  and  by  the  bimanual  touch  it  usually  can  be  proved  to 
be  really  so.  The  shape  of  the 
uterus  is  changed  in  nearly  all 
cases.  It  is  irregular  in  out- 
line, one  side  being  much  larger 
than  the  other.  In  the  subperi- 
toneal variety  this  deformity  is 
quite  marked.  The  tumor  pro- 
jects from  the  surface  of  the 
uterus  so  boldly  that  it  can  be 
instantly  detected.  In  some  of 
the  cases  of  submucous  fibroma, 
and  occasionall}^  in  the  inter- 
stitial, the  uterus  is  uniform  in 
shape  and  appears  like  a  uterus 
enlarged  by  gestation ;  and  even  when  there  is  some  irregularity  of 
form  it  is  not  unlike  that  which  is  often  found  in  pregnancy,  but 
the  uterus  is  very  hard  in  the  one  case,  while  in  the  other  it  is  very 
soft.  The  hard  character  of  the  tumor  and  uterus  is  a  very  reliable 
sign  of  fibroma.  In  all  conditions  which  cause  enlargement,  the 
uterus  is  softened  except  in  fibroma  and  in  very  rare  cases  of  cancer. 
"Whenever  the  uterus  is  enlarged  and  indurated,  fibroma  may  be 
strongly  suspected. 

Deflection  of  the  canal  of  the  uterus  from  the  center  is  a  very 
important  sign  of  fibroma.  The  relations  of  the  canal  of  the  uterus 
to  the  axis  of  the  pelvis,  as  shown  by  the  sound,  are  changed  in  all 
forms  of  displacement,  but  the  canal  is  still  in  the  center  of  the 
uterus.  In  fibroma  the  canal  is  excentric  and  very  often  tortuous. 
The  use  of  the  sound,  by  which  this  displacement  of  the  uterine 
canal  can  be  detected,  gives  this  most  valuable  evidence  of  the  ex- 
istence of  a  fibroma.  Figs.  181  and  182  will  show  this  point  very 
plainly.  The  one  shows  a  uterus  large,  owing  to  subinvolution,  the 
other  about  the  same  size  from  enlaro'ement  due  to  a  fibroid. 

In  not  a  few  cases  the  canal  is  so  deflected,  displaced,  or  com- 
pressed, that  the  sound  can  not  be  passed.  A  flexible  bougie  may 
be  used  under  these  circumstances,  and  although  it  will  not  posi- 
tively show  the  position  of  the  canal,  it  gives  valuable  indications  of 
it.     When  the  sound  can  not  be  used  at  all,  this  valuable  sign  is  not 


366  DISEASES   OP   WOMEN. 

obtainable,  but  the  fact  that  the  canal  in  a  large  uterus  will  not  ad- 
mit the  sound  is  evidence  of  fibroma.  There  is  no  other  condition 
of  enlargement  of  the  uterus  in  which  the  sound  can  not  be  passed, 
as  a  rule. 

Sm.all  fibromata,  which  occupy  the  pelvic  cavity,  present  some 
physical  signs  which  resemble  displacements  of  the  uterus,  ovarian 
tumors,  tubal  pregnancy,  the  products  of  former  inflammations  and 
diseases  of  the  Fallopian  tubes. 

The  differentiation  between  flexions  and  versions  of  the  uterus 
and  fibromata  is  based  upon  the  following  facts  :  In  flexion  and 
version  the  uterus  is  not  much  enlarged,  and,  as  a  rule,  can  be  re- 
stored to  the  proper  position  when  all  signs  suggestive  of  fibroma 
disappear,  and  then,  too,  the  sound  shows  that  the  cavity  of  the 
uterus  is  not  displaced  nor  enlarged.  Ovarian  tumors  are  distin- 
guished from  fibromata  by  being  less  dense  and  not  usually  fixed  to 
the  uterus  ;  one  can  be  moved  without  the  other.  Early  pregnancy 
is  usually  distinguished  from  a  fibroma  by  the  history  and  symp- 
toms, but  the  physical  signs  differ.  The  uterus  is  soft  in  pregnancy, 
while  it  is  unduly  hard  in  fibroma.  The  enlargement  and  softening 
extend  to  the  cervix  in  pregnancy,  but  not  in  fibroma.  Should  a 
doubt  exist,  the  differential  diagnosis  can  easily  be  made  in  a  short 
time  by  watching  the  progress  of  the  case.  The  signs  of  pregnancy 
will  soon  become  sufficiently  pronounced  to  settle  the  question. 

The  most  difficult  cases  to  deal  with  are  those  in  which  preg- 
nancy takes  place  while  there  is  a  fibroma  present.  I  have  seen  sev- 
eral cases  of  this  kind.  Two  of  these  were  pregnant  when  first  seen, 
and  in  both  the  diagnosis  of  fibroma  was  made  and  in  only  one  did 
I  suspect  pregnancy  at  my  first  examination.  In  the  others  I  was 
aware  of  there  being  a  fibroma  present,  but  I  did  not  detect  the 
pregnancy  until  several  months  had  elapsed. 

Fibromata  situated  within  the  folds  of  the  broad  ligament  are  not 
easily  distinguished  from  the  products  of  a  pelvic  cellulitis,  extra- 
uterine pregnancy,  and  disease  of  the  Fallopian  tubes.  The  history 
of  the  case,  taken  in  connection  with  the  physical  signs,  will  usually 
suffice  to  enable  one  to  make  the  diagnosis. 

Large  fibromata  which  occupy  the  abdominal  cavity  have  to  be 
differentiated  from  fibro-cysts  of  the  uterus  and  ovarian  tumors.  In 
regard  to  the  distinctive  signs  by  which  the  diagnosis  between 
ovarian  tumors  and  fibromata  is  made  the  reader  is  referred  to  the 
section  relating  to  the  diagnosis  of  ovarian  tumors. 

The  solid  hard  fil)roma  is  easily  distinguished  from  a  fibro  cyst  of 
the  uterus  by  its  density,  as  recognized   by  the  touch,  but  a  soft 


FIBROMA   OF   THE   UTERUS.  357 

fibroid  may  be  so  elastic  as  to  give  the  signs  of  an  imperfect  fluctua- 
tion, and  simulate  a  cyst  with  a  thick  wall.  In  such  cases  of  doubt 
the  chances  are  in  favor  of  the  tumor  being  a  soft  fibroma,  but  if  it 
is  very  necessary  to  make  a  diagnosis  it  may  be  done  by  aspiration. 
The  accumulation  of  fluid  in  the  upper  part  of  the  cavity  of  the 
uterus,  occurring  as  a  complication  of  a  uterine  fibroma,  gives  the 
physical  signs  of  a  fibro-cyst  so  perfectly  that  one  must  certainly  be 
led  to  make  a  false  diagnosis.  I  have  seen  two  such  cases ;  one  was 
a  very  large  intra-uterine  fibroma  which  closed  the  canal  of  the 
uterus  below  by  pressure  in  the  latter  stages  of  its  growth.  The 
secretions  of  the  mucous  membrane  accumulated  at  the  fundus  and 
gave  distinct  fluctuation.  One  of  the  most  distinguished  gyne- 
cologists of  this  age  saw  the  patient  with  me,  and  thought,  as  I  did, 
that  it  was  a  fibro-cyst,  but  it  was  not. 

The  histories  of  these  cases,  especially  one  which  is  given  further 
on,  will  show  more  fully  the  peculiar  character  of  the  pathology  and 
the  dilficulties  of  diagnosis. 

Causation. — The  causation  of  uterine  fibromata  remains  as  ob- 
scure as  ever.  Granting  that  they  are  the  results  of  lesion  of  evolu- 
tion leaves  the  question  of  the  derangement  of  development  unset- 
tled. Heredity  may  probably  have  something  to  do  with  it.  A 
lesion  in  the  arrangement  of  the  fiber  of  tissue  might  be  transmitted 
as  surely  as  the  distribution  of  colors.  The  fact  that  these  neoplasms 
prevail  in  certain  families  and  races  favors  this  theory.  Certain 
facts  in  regard  to  age,  race,  and  social  relations  have  been  ascer- 
tained which  favor  the  growth  of  these  neoplasms.  The  age  when 
fibromata  grow  is  between  thirty  and  thirty-five  years.  There  are 
many  exceptions  to  this,  however,  but  it  is  rare  to  have  these  growths 
appear  before  puberty  or  after  the  menopause.  It  may  be  more 
correct  to  say  that  they  never  attain  any  appreciable  size  befoi-e  pu- 
berty and  rarely  after  the  menopause.  In  regard  to  race,  the  negro 
is  more  liable  to  fibromata  than  the  white,  although  no  good  reason 
has  been  discovered  why  this  is  the  case.  The  influence  of  the  so- 
cial relations  is  stated  by  Thomas  Addis  Emmet  as  follows : 

"  The  development  of  these  growths  is  retarded  by  child-bearing, 
and  even  by  marriage,  for  the  sterile  M^oman  is  less  liable  than  the 
old  maid,  but  in  turn  she  is  more  so  than  the  woman  who  has  borne 
children."  These  facts  are  deductions  from  large  tabulated  observa- 
tions of  cases  by  Dr.  Emmet.  He  also  gives  his  views  regarding 
the  social  state  as  related  to  the  causation  of  these  neoplasms  in  the 
following  woi'ds  : 

"  Between  the  ages  of  thirty  and   forty  years  the  unmarried 


368  DISEASES  OF  WOMEN. 

woman  is  fully  twice  as  sul)ject  to  fibrous  tumors  as  the  sterile  or 
the  fruitful.  I  have  already  referred  to  this  subject,  when  treating 
of  the  causes  of  disease,  and  pointed  out  that  this  is  one  of  the 
tributes  which  an  unmarried  woman  pays  for  her  celibacy.  It  seems 
as  if  it  were  the  purpose  of  jS^ature  that  the  uterus  should  undergo 
the  changes  dependent  upon  pregnancy  and  lactation  about  once  in 
three  years  throughout  the  child-bearing  period,  and  that  if  the 
uterus  is  not  physiologically  occupied  in  child-bearing  there  is  greater 
liability  to  the  development  of  fibrous  tumors  as  the  woman  advances 
in  life.  This  will  also  be  the  case  with  the  married  woman  who  has 
taken  means  to  prevent  conception,  as  well  as  with  her  who  has  been 
sterile  from  some  cause  beyond  her  control,  but  to  a  less  degree  in 
the  latter  case.  I  think  I  have  had  occasion  to  note  that  the  sterile 
woman  who  has  earnestly  wished  for  children  does  not  have  her 
liability  to  fibrous  tumor  increased  by  the  fact  of  her  sterility — an 
instance,  probably,  of  the  remarkable  effect  of  mind  upon  the  body. 
Finally,  the  woman  who  may  have  been  fruitful  in  early  life,  but 
remained  sterile  long  afterward  from  some  accidental  cause,  may 
have  a  tumor  developed,  but  is  less  liable  thereto  from  having  once 
borne  a  child." 

From  my  point  of  view,  the  statements  of  Dr.  Emmet  given 
above  refer  to  the  growths  of  fibromata,  not  to  their  genesis  or  de- 
velopment. 

Prognosis. — Fibromata  of  the  uterus,  while  the  most  frequently 
seen  of  all  the  neoplasms  of  the  sexual  organs,  are  the  most  harmless 
so  far  as  their  tendency  to  destroy  life.  They  occasion  suffering, 
but  rarely  prove  fatal.  Many  patients  are  unable  to  live  on  until 
the  menopause,  when  the  tumors  disappear  altogether,  or  become 
reduced  during  the  final  involution  of  the  uterus  so  that  they  are 
harmless. 

The  complications  are,  first,  haemorrhage,  which  recurs  so  often  in 
many  cases  that  it  endangers  life.  Very  few  patients  bleed  to  death 
directly,  but  some  become  so  reduced  by  the  long-continued  loss  of 
blood,  which  impairs  nutrition,  that  death  comes  as  the  result  of  some 
secondary  affection  which  would  not  have  occurred  except  for  the 
exhausted  state  of  the  patient.  Peritonitis  and  cellulitis  are  liable 
to  be  set  up  by  fibroma,  and  of  the  fatal  cases  peritonitis  is  a  not 
infrequent  cause.  Softening  of  the  tumor  and  decomposition  may 
cause  a  fatal  septicemia.  Blood-poisoning  sometimes  occurs  during 
the  expulsion  of  intra-uterine  fibroma.  The  tumor,  being  in  part 
cut  off  from  the  circulation,  undergoes  necrosis  before  its  expulsion 
is  completed,  and  causes  septica3mia,  and  death  takes  place  when 


FIBROMA  OP  THE   UTERUS.  369 

relief  and  recovery  appear  to  be  within  the  immediate  reach  of  the 
sufferer.  Pressure  upon  the  pelvic  organs  may  cause  death  by  arrest- 
ing the  functions  of  these  organs.  This  is  most  likely  to  take  place 
when  the  tumor  grows  in  the  broad  ligament  and  is  therefore  fixed 
in  the  pelvis.  I  have  also  seen  death  occur  from  pressure  upon  the 
ureters  causing  obstruction  to  the  llow  of  urine,  renal  disease,  and 
Anally  uraemia.  Although  there  are  dangers  from  all  of  the  com- 
plications named  above,  the  number  of  fatal  cases  is  very  small  even 
when  left  without  treatment ;  and  by  judicious  management  a  large 
number  can  be  relieved  entirely,  or  helped  sufiiciently  to  be  able  to 
pass  through  life  in  comparative  comfort.  Within  the  past  few 
years  such  means  as  ovariotomy,  hysterectomy,  and  electrolysis  have 
been  employed  in  the  treatment  of  uterine  fibroma,  with  results 
which  raise  the  hope  that  the  great  majority  of  these  neoplasms 
will  be  controlled,  and  the  death-rate  from  this  cause  reduced  to  a 
minimum. 

Treatment. — The  size  and  location  of  uterine  fibromata,  and  the 
conditions  and  complications  produced  by  them,  differ  very  greatly, 
and  hence  the  treatment  must  vary  with  each  case.  Uterine  fibro- 
mata, when  discovered  in  the  rudimentary  or  latent  state,  are  amen- 
able to  treatment.  A  careful  study  of  many  cases  has  convinced 
me  that  these  tumors  are  disposed  to  remain  in  a  latent  state  until 
they  come  under  conditions  favoring  their  growth,  such  as  sterility, 
deranged  menstruation,  and  endometritis.  In  other  words,  it  is 
more  easy  to  keep  a  fibroid  from  beginning  to  grow  than  to  arrest 
its  growth  after  it  has  begun.  It  is  evident  that  any  derangement 
■of  the  functions  of  the  uterus  favors  growth  of  fibromata.  It  natu- 
rally follows  that  the  relief  of  any  diseases  of  the  uterus  which  de- 
range or  interrupt  any  of  its  functions  will  indirectly  control  the 
growth  of  fibromata.  This  I  have  demonstrated  many  times.  I 
have  on  record  a  number  of  cases  of  imperfect  development  with 
small  fibi-oids  of  the  uterus,  manifested  by  irregular  and  painful 
menstruation,  that  upon  being  relieved  of  the  malformation  and 
impaired  nutrition  have  suffered  nothing  from  the  fibroids.  Sev- 
eral patients  after  being  cured  have  become  pregnant,  and  while  the 
fibromata  appeared  to  increase  in  three  of  them  during  gestation, 
they  reduced  in  size  during  post-partum  involution  of  the  uterus. 
In  eighteen  cases  of  pregnancy  with  fibroma  of  the  uterus,  seven 
miscarried  and  eleven  were  delivered  at  full  term  ;  two  of  them 
were  twice  delivered  safely.  The  subsequent  histories  of  ten  were 
kept  for  periods  varying  from  one  to  four  years,  and  in  only  one 
did  the  fibroma  grow  to  any  appreciable  extent. 


3Y0  DISEASES  OF  WOMEN. 

In  some  of  my  cases  the  tumors  had  attained  considerable  size 
before  gestation  took  place,  and  as  they  remained  stationary,  for 
some  time  certainly  after  confinement,  it  appears  that  gestation  re- 
tarded their  growth. 

The  indications  for  treatment  (when  fibromata  are  rudimentary 
and  latent,  and  also  when  they  are  growing  but  are  small)  are  to 
remove  all  malformations,  malpositions,  and  inflammations,  or  other 
curable  lesions  that  may  be  present ;  in  short,  to  restore  the  uterus 
to  its  normal  structure  so  that  it  may  perform  its  functions.  When 
this  is  accomplished  the  growth  of  fibromata  is  prevented  in  the 
great  majority  of  cases. 

The  above  may  be  called  the  preventive  treatment — that  is, 
treatment  which  prevents  growth.  When  this  fails,  or  in  cases  hav- 
ing progressed  far  enough  to  cause  trouble,  the  treatment  required 
is  of  an  entirely  different  character. 

The  ways  and  means  may  be  said  to  vary  from  the  simplest 
medication  to  the  most  daring  surgery,  and  each  method,  if  judi- 
ciously adapted  to  the  requirements  of  cases  as  they  come,  gives 
satisfactory  results. 

Medicinal  agents  have  been  employed  in  great  variety,  but  ergot 
alone  has  been  found  of  real  value.  The  action  of  ergot  upon 
fibromata  may  accomplish  beneficial  effects  in  two  ways.  By  excit- 
ing uterine  contractions,  it  may  produce  expulsion  of  the  tumor  if 
its  relations  to  the  uterine  wall  are  such  that  it  can  be  expelled. 
On  this  account  ergot  does  its  best  work  in  the  submucous  variety 
of  uterine  fibromata.  In  the  same  way  the  ergot,  by  causing  con- 
traction of  the  uterine  walls,  may  lessen  the  area  of  attachment  of  a 
subperitoneal  fibroma,  and  arrest  or  retard  its  growth  by  lessening 
its  blood-supply.  This  view  of  the  beneficial  effects  of  ergot  upon 
the  progress  of  subperitoneal  fibromata  is  based  upon  the  fact  that 
when  such  tumors  are  pedunculated  they  do  not,  as  a  rule,  grow  so 
fast  as  when  they  arc  attached  to  the  uterus  by  a  broad  base.  In 
this  respect  the  action  of  ergot  is  simply  to  aid  in  the  natural 
method  of  disposing  of  these  growths — viz.,  by  expulsion,  which  in 
the  submucous  or  intra-uterine  variety  is  often  complete,  the  growth 
being  wholly  expelled  from  the  uterus. 

Ergot  also  acts  in  another  way  to  arrest  the  growth  of  such  tu- 
mors. By  keeping  the  uterus  in  a  condition  of  permanent  contrac- 
tion, and  by  contracting  the  blood-vessels,  the  size  of  the  tumor  is 
diminished,  and  atrophy  takes  place.  In  order  to  obtain  the  good 
effects  of  ergot  in  this  way,  it  must  be  given  in  liberal  doses,  sufii- 
cient  at  least  to  produce  all  the  contractions  of  the  uterus  that  the 


FIBROMA  OF   THE   UTERUS.  371 

patient  can  endure  the  pains  of,  and  it  must  be  continued  for  a  long 
time.  It  sometimes  happens  that  the  patient  can  not  take  ergot  for 
any  length  of  time  without  having  indigestion  and  loss  of  appetite ; 
occasionally,  also,  the  uterus  fails  to  contract  in  response  to  full  doses 
of  this  drug.  In  either  case  it  is  useless,  and  should  not  be  con- 
tinued. 

In  some  cases  the  use  of  ergot,  while  it  does  not  diminish  the 
size  of  the  tumor  nor  aid  in  its  expulsion,  appears  to  retard  its 
growth,  and  it  also  controls  the  bleeding,  which  is  a  great  gain. 
When  the  patient  can  be  guarded  against  the  great  loss  of  blood,  she 
may  be  enabled  to  live  in  comparative  comfort  and  usefulness  until 
the  menopause. 

Electrolysis. — This  method  takes  a  high  rank  among  the  means 
of  treating  fibroma  of  the  uterus.  In  order  to  fully  comprehend 
this  subject,  some  knowledge  of  the  elements  of  electro-physics 
should  be  obtained.  For  this  we  must  refer  our  readers  to  the  text- 
books on  this  subject. 

Method  of  applying  Electrolysis  in  the  Treatment  of  Fibroid  Tu- 
mors.— The  method  of  using  the  current  which  I  have  adopted  is  to 
pass  an  electrode  into  the  cavity  of  the  uterus,  and  insulate  that 
portion  of  the  instrument  which  rests  in  the  vagina.  The  other 
electrode — a  broad  one — is  applied  over  the  abdominal  surface 
where  the  tumor  is  located.  The  electrode  in  the  uterus  is  con- 
nected with  the  negative  pole  of  the  battery,  and  the  other  with  the 


Fig.  183. — Uterine  electrode. 


positive.  The  current  is  then  gradually  turned  on,  until  it  is  as 
strong  as  the  patient  can  tolerate  and  is  continued  for  eight  or 
ten  minutes.  This  is  repeated  every  third  or  fourth  day.  The 
electrode  which  is  introduced  into  the  uterus  is  shaped  like  a  uterine 
sound.  The  portion  of  it  which  occupies  the  cavity  of  the  uterus  is 
made  of  platinum.  The  rest  is  copper  covered  with  hard  rubber, 
and  over  this  there  is  a  sheath  of  rubber,  which  can  be  moved  for- 
ward or  backward  to  regulate  the  length  of  the  portion  to  be  insu- 
lated, which  varies,  according  to  the  depth  of  the  canal  of  the  uterus 
in  different  cases. 

Fig.  183  shows  this  instrument.  The  electrode  which  Apostoli 
uses  for  the  outside  of  the  tumor  is  composed  of  sculptors'  clay, 
rolled,  cut  to  a  size  sufficient  to  cover  the  prominent  part  of  the 


372  DISEASES  OF  WOMEN". 

tnmor,  and  about  half  or  three  quarters  of  an  inch  thick.  The  clay 
is  covered  with  some  thin  fabric,  like  cheese-cloth,  to  keep  it  to- 
gether. This  is  applied  over  the  abdomen,  and  then  a  broad  me- 
tallic plate  applied  over  the  clay.  This  answers  very  well  so  far  as 
fitting  the  rounded  abdominal  surface,  and  by  its  own  weight  it 
keeps  its  place  and  also  protects  the  skin  from  irritation.  It  is  not 
very  convenient,  however.  The  clay  has  to  be  kept  wet  all  the 
time,  in  order  to  be  ready  for  use  when  needed.  It  also  requires 
to  be  made  M-arm  in  cold  weather,  and  is  not  very  clean  to  handle. 
Owing  to  these  inconveniences  of  the  clay,  other  materials  have 
been  used.  I  employ  a  sheet  of  absorbent  cotton  about  half  an  inch 
thick  when  wet,  and  gently  compressed,  and  over  that  an  electrode 
made  of  a  number  of  small  metallic  plates  fastened  together  with 
wire.  In  this  way  the  electrode  fits  the  irregular  curves  of  the  ab- 
dominal walls.  Even  this  is  not  exactly  what  I  desire.  While  it  is 
free  from  the  objections  of  the  clay,  it  does  not  adapt  itself  to  the 
body  as  well  as  the  clay.  This  leads  me  to  believe  that  something 
more  convenient  than  anything  now  in  use  may  yet  be  devised. 

This  is  the  method  of  using  electrolysis  in  the  way  which 
appears  to  me  to  be  most  acceptable,  but  there  are  modifications  as 
practiced  by  some  which  should  be  noticed. 

Some  prefer  to  anassthetize  the  patient  and  use  a  current  stronger 
than  the  patient  could  otherwise  bear.  This  may  insure  more  rapid 
progress  in  the  treatment,  but  it  is  perhaps  more  dangerous  and 
disagreeable  to  the  patient.  I  prefer  a  current  which  the  patient 
can  tolerate,  and  continue  it  longer  at  a  time  and  repeat  the  treat- 
ment oftener. 

It  not  infrequently  happens  that  the  cervix  uteri  is  displaced,  so 
that  the  electrode  can  not  be  introduced  into  the  uterine  cavity.  In 
such  cases  a  needle-pointed  electrode  should  be  thrust  into  the  tumor 
and  the  current  passed  in  the  usual  way.  Apostoli  speaks  of  this  as 
making  an  artificial  canal  in  place  of  the  normal  one  of  the  uterus. 

In  order  to  maintain  this  canal  made  by  the  first  puncture,  the 
current  used  must  be  strong  enough  to  destroy  the  tissues  in  imme- 
diate contact  with  the  instrument.  Should  the  opening  close,  another 
puncture  can  be  made  at  the  next  treatment. 

In  cases  where  there  is  severe  menorrhagia  Apostoli  recommends 
the  introduction  of  a  positive  electrode  into  the  uterus,  and  the  use 
of  a  current  strong  enough  to  slightly  char  or  dry  the  mucous  mem- 
brane, and  in  that  way  arrest  the  bleeding.  This  is  no  doubt  good 
practice  when  the  bleeding  can  not  be  arrested  by  other  means,  such 
as  curetting  or  the  application  of  astringents. 


FIBROMA  OF  THE  UTERUS. 


37i 


Menorrhagia,  when  it  is  present,  can  sometimes  be  helped  by 
treating  tlie  endometrium. 

The  endometritis  is  often  attended  witli  fungous  growths  which 
greatly  increase  the  tendency  to  haemorrhage.  The  removal  of  such 
fungosities  with  the  curette  will  often  give  relief,  and  the  subse- 
quent application  of  tincture  of  iodine  to  the  uterine  mucous  mem- 
brane at  regular  intervals  is  of  service.  In  order  to  use  the  curette 
and  apply  the  iodine,  it  is  necessary  that  the  cervical  canal  should 
be  sufficiently  large  to  permit  an  entrance  to  the  uterine  cavity.  In 
some  cases  the  cervical  canal  is  so  narrow  and  the  cavity  of  the 
uterus  so  deflected  that  to  reach  it  is  sometimes  impossible.  In 
such  conditions  sufficient  drainage  after  treatment  is  not  obtainable, 
and  hence  the  very  great  danger. 

When  expulsion,  with  or  without  the  use  of  ergot,  has  advanced 
far  enough  to  pedunculate  an  intra-uterine  tumor  and  dilate  the  cer- 
vix uteri,  the  tumor  can  be  separated  from  the  uterine  wall  by 
dividing  the  pedicle.     When  the  dilatation  of  the  cervix  is  complete. 


TOP  VIEW. 

Fig.  184. — Ecraseur. 


and  the  tumor  is  expelled  from  the  uterus  and  lodged  in  the  vagina 
(the  pedicle  still  remaining  attached  to  the  uterus),  the  separation 
and  removal  of  the  tumor  are  quite  easy. 

There  are  several  methods  of  dividing  the  pedicle.  I  prefer  to 
use  the  wire  ecraseur .  The  galvano-cautery  ecraseur  has  been  used, 
but  it  is  difficult  to  apply,  and  it  is  impossible  to  avoid  burning  the 
uterus  and  vagina ;  it  has  no  advantages  over  the  wire  or  chain. 

The  ecraseur  which  I  use  is  modified  to  suit  the  wire.  The  por- 
tion to  which  the  wire  is  attached  is  so  arranged  that  each  end  of 
the  wire  is  held  fast  by  a  pinching  screw,  so  that  the  loop  of  wire 
can  be  lengthened  or  shortened  in  a  moment  (Fig.  184).  I  employ 
the  steel  wire  used  for  piano  or  zither  strings,  the  thickness  of  the. 
wire  being  adapted  to  the  size  of  the  pedicle.  The  wire  has  one 
very  great  advantage  over  the  chain  in  being  easily  applied.  It  is 
elastic,  and  yet  stiff  enough  to  be  easily  made  to  slip  over  the  tumor 
to  be  snared. 


374 


DISEASES  OP  WOMEN. 


Objections  to  the  wire  or  chain  eci^aseur  have  been  raised.  There 
is  danger,  it  has  been  claimed,  of  the  uterine  wall  being  drawn 

into  the  grasp  of  the  chain  and  a 
part  of  it  removed,  and  an  opening 
made  directly  into  the  peritoneal 
cavity.  The  fact  is,  that  as  the  wire 
is  tightened  around  the  pedicle  the 
tissues  are  forced  out  of  its  grasp 
equally  on  both  sides.  There  is  no 
drawing  of  the  tissues  into  the  grasp 
of  the  wire. 

If  there  is  inversion  of  the  uterus 
at  the  point  of  attachment  of  the 
pedicle,  the  wall  of  the  uterus  might 
be  included  in  the  ecraseur  wire 
and  removed.  This  happened  once 
in  my  own  practice,  and  I  believe 
the  same  thing  has  been  done  by 
other  operators.  Fig.  185  shows 
the  condition  referred  to  as  it  oc- 
curred in  my  own  patient. 

The  inversion  of  part  of  the 
uterus  was  not  detected  before  the 
operation  was  completed,  but  an  ex- 
amination of  tlie  tumor  showed  that 
the  inverted  portion  of  the  uterine 
No  harm  came  from  it.  The  patient 
did  well,  but  the  greatest  anxiety  was  felt  for  some  time. 

Sometimes  it  happens  that  the  tumor,  while  it  protrudes  into  the 
vagina  to  a  slight  extent,  is  grasped  by  the  cervix  so  firmly  that  the 
wire  of  the  ecraseur  can  not  be  applied.  The  same  difficulty  has 
been  encountered  when  the  tumor — the  size  of  a  fetal  head — is 
lodged  in  the  vagina.  Under  such  circumstances,  the  tumor  should 
be  reduced  by  rapidly  taking  sections  of  it  away  with  a  strong 
scissors,  and  then  the  ecraseur  can  be  used,  or  if  the  haemorrhage 
is  not  great  the  base  of  the  tumor  should  be  enucleated. 

Much  care  and  gentle  handling  of  the  enucleating  instrument 
should  1)0  employed,  because  the  muscular  wall  of  the  uterus  at  the 
point  of  attachment  of  the  tumor  may  be  absorbed,  and  the  base  of 
the  tumor  rest  upon  the  peritonaeum.  This  state  of  affairs  I  have 
found  in  two  cases  wliich  I  treated  by  enucleation,  the  histories  of 
which  will  be  given. 


Fig.  185. — Wall  of  uterus  caught  in 
ec/-«seMr-wire  and  removed. 

wall  was  completely  removed. 


FIBROMA  OF  THE  UTERUS.  375 

Intra-uterine  fibromata  have  been  treated  by  enucleation  l^efore 
tliey  became  pedunculated,  and  before  the  cervix  was  dilated.  Dila- 
tation or  descision  of  the  cervix  was  made  and  the  tumor  enucleated. 
When  the  tumor  was  high  up  the  capsule  was  incised,  and  ergot 
given  to  bring  the  tumor  within  reach  of  the  operator. 

At  one  time  this  treatment  was  quite  in  vogue  in  this  country. 
The  operation  is  difficult  and  dangerous,  and  the  results  so  unsatis- 
factory that  it  was  abandoned  years  ago. 

Removal  of  the  ovaries  for  the  relief  of  small  fibromata  which 
cause  exhausting  haemorrhage  has  given  satisfactory  results.  This 
plan  of  treatment  was  suggested  by  the  fact  that  these  neoplasms 
disappear,  as  a  rule,  after  the  menopause.  Reasoning  from  this,  it 
was  pi'esnmed  that  by  removing  the  ovaries,  and  thereby  inducing 
the  cessation  of  the  menstrual  function  prematurely,  the  same  effect 
upon  the  fibromata  would  be  obtained.  It  was  found  to  be  so,  and 
hence  in  properly  selected  cases  the  removal  of  the  ovaries  gave 
■excellent  results.  Since  hysterectomy  has  been  perfected  the  re- 
moval of  the  ovaries  for  the  cure  of  fibroids  has  been  abandoned  by 
the  vast  majority  of  surgeons. 

Supra-vaginal  Hysterectomy. — The  evolution  of  this  operation  is 
most  interesting,  and  were  this  work  in  any  degree  historical  a 
<3hapter  on  the  subject  would  be  required. 

In  the  beginning,  the  uterus  proper  was  removed,  and  the  cervix 
left  as  a  pedicle,  which  along  with  the  broad  ligaments  was  included 
in  a  clamp  and  left  in  the  lower  end  of  the  wound.  It  was  impos- 
sible in  this  way  to  apply  the  clamp  at  the  junction  of  the  body  and 
■cervix  without  including  a  part  of  the  bladder  or  making  extreme 
traction  of  the  outer  portion  of  the  broad  ligaments.  The  stump 
formed  in  that  way  was  very  large  and  very  unsatisfactory.  Keith 
overcame  this  difficulty  by  clamping  the  broad  ligaments  and  sepa- 
rating them  from  the  uterus,  and  also  dissecting  off  the  bladder  in 
front,  when  necessary,  so  that  the  uterus  could  be  raised  up  and  the 
clamp  applied  at  the  upper  portion  of  the  cervix  uteri.  The  broad 
ligaments,  being  freed  from  the  fundus  uteri,  were  included  in  the 
■clamp  without  traction.  Many  modifications  of  this  extra-peritoneal 
method  of  treating  were  introduced  by  Hager,  Treub,  Martin,  and 
•others,  but  none  proved  sufficiently  satisfactory  to  stay.  Though 
most  excellent  results  were  obtained  in  this  way  the  convalescence 
was  slow,  and  Keith  and  others  sought  for  some  way  of  treating  the 
pedicle  by  the  intra-peritoneal  method,  the  same  as  in  ovariotomy. 
Schroder,  Martin,  A.  Palmer  Dudley,  and  others,  after  ligating  the 
broad  ligaments,  amputated  at  the  junction  of  the  body  and  the 


376  DISEASES  OF  WOMEN. 

cervix  uteri,  and  sutured  the  stump  and  covered  it  witli  the  peri- 
tonaeum. 

The  results  were  not  equal  to  those  obtained  by  subsequent  im- 
provements, such  as  the  method  of  B.  F.  Baer.  His  method  of 
operating  is  so  much  in  advance  of  the  older  ways  that  I  quote  his 
own  description  of  it : 

"  After  the  required  abdominal  incision  is  made,  all  existing  ad- 
hesions of  omentum,  intestines,  etc.,  are  separated  in  the  usual  way, 
and  the  tumor  lifted  out  of  the  abdominal  cavity.  If  the  incision 
has  been  an  unusually  lengthy  one,  several  sutures  are  placed  at  its 
upper  end  for  the  better  protection  of  the  intestines.  The  patient 
may  now  be  elevated  to  the  Trendelenburg  posture,  if  deemed  best, 
and  the  parts  thoroughly  studied,  so  that  a  clear  idea  as  to  the  char- 
acter and  location  of  the  tumor  and  pedicle  may  be  obtained  before 
the  ligation  and  separation  are  begun.  The  first  step  in  the  opera- 
tion is  the  passing  of  a  single  silk  suture  through  the  broad  ligament, 
near  the  cervix.  This  ligature  is  again  made  to  transfix  the  broad 
ligament  near  its  outer  edge,  to  prevent  slipping ;  it  is  then  tied. 
A  stout  pedicle  forceps  is  next  placed  under  the  Fallopian  tube  and 
ovary,  and  made  to  grasp  the  broad  ligament  for  the  purpose  of 
preventing  reflux  from  the  uterus.  The  ligament  is  now  severed 
just  below  the  forceps,  the  incision  being  carried  close  to  the  tissue 
of  the  tumor.  If  deemed  necessary,  another  ligature  is  now  passed 
through  the  broad  ligament  farther  down  along  the  side  of  the 
cervix.  This  ligation  and  cutting  are  now  repeated  on  the  opposite 
side.  The  knife  is  then  run  lightly  around  the  tumor  an  inch  or 
two  above  the  peritoneal  reflexion  of  the  bladder  in  front,  probably 
a  little  lower  behind,  and  the  severed  edges  of  the  peritonaeum 
strii)ped  down  with  the  handle  of  the  scalpel  for  the  purpose  of 
making  peritoneal  flaps.  The  next  step  is  a  most  important  one : 
it  is  the  ligation  of  the  uterine  arteries.  This  is  done  in  the  broad 
ligaments,  outside  of  but  close  to  the  cervix.  Care  must  be  taken 
to  avoid  the  ureter  on  the  one  hand  and  the  cervical  tissue  on  the 
other.  The  ligature  may  either  be  placed  within  the  folds  of  the 
severed  ligament,  or,  which  is  preferable,  made  to  encircle  the  double 
fold  of  the  ligament  and  artery  in  one  sweep ;  action  here  will  de- 
pend upon  the  size  of  the  pedicle  and  the  consequent  separation  of 
these  folds.  The  constant  traction  which  is  made- upon  the  pedicle 
by  the  assistant,  who  is  holding  the  tumor,  serves  to  draw  out  and 
elongate  the  cervix  after  the  peritoneal  covering  has  been  incised, 
and  thereby  to  permit  deeper  incision  into  the  neck,  which  is  next 
amputated  with  the  knife  by  a  sort  of  cupped  incision.     The  stump 


FIBROMA  OF  THE  UTERUS.  377 

is  now  grasped  with  a  small  volsella  forceps,  and  further  trimmed 
and  reduced,  if  necessary,  so  that  the  entire  supra-vaginal  portion  is 
removed  before  it  is  dropped  back  into  the  pelvis.  The  cervix  being 
now  released,  it  immediately  recedes,  and  is  drawn  deeply  into  the 
pelvis  by  the  retractive  and  elastic  properties  of  the  vagina,  where 
it  is  buried  out  of  sight  by  the  peritoneal  flaps  covering  it.  These 
flaps  have  been  rendered  so  taut  by  the  ligatures  which  have  been 
placed  that  usually,  as  the  cervix  recedes  into  the  pelvis,  they  close 
over  it  like  elastic  bands.  The  cervix  is  now  in  its  natural  position, 
and  without  a  ligature  or  suture  in  its  tissues.  The  operation  is 
finished  by  infolding  the  edges  of  tlie  peritoneal  flaps,  which  may 
be  secured  by  Lembert  sutures,  if  necessary.  I  have  not  found  this 
necessary  if  the  ligatures  which  secured  the  uterine  arteries  have  also 
grasped  the  several  folds  of  the  broad  ligaments,  for  this  so  tightens 
them  that  the  sides  are  brought  forcibly  together  when  the  cervix  is 
drawn  under.  If  any  other  vessels  are  found  spurting,  they  are,  of 
course,  ligated." 

Abdominal  Hysterectomy. — The  operation  which  I  have  adopted 
is  that  practiced  and  described  by  Prof.  Howard  A.  Kelly,  of  Balti- 
more.    I  quote  his  description  in  full : 

"  The  operation  consists  in  the  following  steps : 

"  1.  Opening  the  abdomen. 

"  2.  Ligation  of  the  ovarian  vessels  near  the  pelvic  brim,  either 
on  the  right  or  on  the  left  side,  clamping  them  toward  the  uterus, 
and  cutting  between. 

"  3.  Ligating  the  round  ligament  of  the  same  side  near  the 
uterus,  cutting  it  free,  and  connecting  the  two  incisions,  in  order  to 
open  up  the  top  of  the  broad  ligament. 

"4.  Incision  through  the  vesico-uterine  peritonaeum  from  the 
severed  round  ligament  across  to  its  fellow,  freeing  the  bladder, 
which  is  now  pushed  down  with  a  sponge,  so  as  to  expose  the  supra- 
vaginal cervix. 

"  5.  Pulling  the  body  of  the  uterus  to  the  opposite  side  to  ex- 
pose the  uterine  artery  low  down  on  the  side  opened  up.  The  vagi- 
nal portion  of  the  cervix  is  located  with  thumb  and  forefinger,  and 
the  uterine  artery,  seen  or  felt,  is  tied  just  where  it  leaves  the 
uterus.     It  is  not  always  necessary  to  tie  the  veins. 

"  6.  The  cervix  is  now  cut  completely  across  just  above  the 
vaginal  vault,  severing  the  body  of  the  uterus  from  the  cervical 
stump,  which  is  left  below  to  close  the  vault. 

"  Y.  As  the  last  fibers  of  the  cervix  are  severed  or  pulled  apart, 
while  the  body  of  the  uterus  is  being  drawn  up  and  rolled  out  in 


378 


DISEASES  OP  WOMEN. 


Fig.  186. — Showing  line  of  incision  through  peritonfcum 
from  left  to  right,  through  left  broad  ligament, 
round  ligament,  utero-vesical  peritonEEum,  right 
round  ligament,  and  ending  with  right  broad  liga- 
ment near  the  pelvic  brim.     (Kelly.) 


the  opposite  direction,  the  other  uterine  artery  comes  into  view  and 

is  caught  with  artery  forceps  about  an  inch  above  the  cervical  stump. 

"  8.  Rolling  the  uterine  body  still  farther  out,  the  right  round 

ligament  is  clamped  and  cut  off,  and  lastly  the  ovarian  vessels  are 

clamped  at  the  pelvic 
brim,  and  the  removal 
of  the  whole  mass,  con- 
sisting of  uterus,  tubes, 
and  ovaries,  is  com- 
pleted. 

"  9.  Ligatures  are 
now  applied  in  place  of 
the  forceps  holding  the 
uterine  artery,  round 
ligament,  and  ovarian 
vessels ;  if  the  surgeon 
prefers,  these  may  be 
tied  as  they  are  exposed 
without  using  forceps. 
"  10.  After  the  enucleation  the  operation  is  now  finished  in  the 
usual  way — {a)  by  closing  the  cervical  tissue  over  the  cervical 
canal,  and  then  (b)  by  drawing  the  peritonaeum  of  the  anterior  part 
of  the  pelvis  (vesical  peritonaeum  and  anterior  layers  of  broad  liga- 
ments) over  the  entire  wound  area,  and  attaching  it  to  the  posterior 
peritonaeum  by  a  continuous  catgut  suture. 

"  The  continuous  transverse  incision  should  always  be  started  on 
the  side  where  the  ovarian  vessels  and  the  ovary  and  tube  are  most 
accessible.  If  the  case  is  one  of  a  fibroid  uterus,  and  the  tumors 
are  developed  under  the  pelvic  peritonaeum  or  in  the  broad  ligament 
of  one  side,  this  side  should  be  opened  up  last,  from  below  upward, 
when  the  tumors  can  be  rolled  up  and  out  with  surprising  facility. 

"  Displaced  ureters  will  not  be  injured,  for  on  the  side  on  which 
the  enucleation  is  started  such  a  ureter  is  pushed  down  with  the  loose 
peritonaeum  as  the  uterus  and  tumors  are  pulled  up  and  toward  the 
opposite  side ;  and  on  the  other  side,  no  matter  how  much  the  ure- 
ter is  displaced  out  of  the  pelvis,  as  tlie  tumors  caught  from  below 
are  rolled  up  and  out,  the  ureter  drops  down  with  the  peritonaeum 
and  cellular  tissue  to  the  pelvic  floor,  and  the  operator  need  not 
even  see  it  or  be  aware  of  its  displacement  to  avoid  the  risk  of  in- 
juring it. 

"  If  the  ureter  is  found  to  be  displaced  only  on  one  side,  the  op- 
eration should  begin  on  the  opposite  side. 


FIBROMA  OF   THE  UTERUS. 


3Y9 


"  To  escape  the  danger  of  tying  the  ureter  on  the  side  on  which 
the  uterine  artery  is  caught  after  dividing  the  cervix,  I  am  careful 
to  put  tlie  forceps  on  the  artery  well  above  the  cervical  stump  and 
to  tie  there. 

"  The  abdominal  incision  is  always  closed  without  drainage  by 
using  a  continuous  catgut  suture  for  the  peritonaeum,  interrupted 


Ov.ves. 


ilouncL  lig. 


Fig.  18*7. — Left  ovarian  vessels  tied,  left  round  ligament  tied,  vesical  peritonfeum  divided 
and  pushed  down  and  left  uterine  vessels  ligated.  Cervix  amputated  and  uterus 
pulled  up  and  out,  exposing  right  uterine  artery,  which  is  clamped  an  inch  above 
the  cervical  stump.  The  two  following  steps  are  clamping  the  right  round  ligament 
and  right  ovarian  vessels,  when  the  mass  is  removed.     (Kelly.) 


silver- wire  sutures  for  the  fascia,  a  buried  continuous  catgut  suture  for 
the  subcutaneous  fat,  and  the  subcuticular  catgut  suture  for  the  skin. 

"  The  important  points  accomplished  by  this  method  of  operat- 
ing are  {a)  the  great  saving  of  time,  and  (b)  the  simple  way  in  which 
certain  serious  complications  are  met. 

"  {a)  Time  saved. — According  to  other  methods  of  operating, 
half  an  hour  or  an  hour,  or  even  more,  may  be  consumed  in  enu- 


380  DISEASES   OF   WOMEN. 

cleating  the  tumors  and  in  getting  ready  to  close  up  the  pelvic  and 
abdominal  wounds,  while  by  this  method  the  enucleation  is  often 
effected  in  three  or  four  minutes,  and  in  difficult  cases  in  from  ten 
to  fifteen  minutes. 

"  The  experience  of  every  surgeon  will  bear  me  out  in  insisting 
upon  the  importance  of  saving  time  at  this  particular  stage  of  the 
operation — that  is,  the  stage  of  enucleation — which  is  most  likely, 
when  prolonged,  to  produce  shock  and  to  be  accompanied  by  ex- 
cessive loss  of  blood. 

"  Furthermore,  when  the  enucleation  of  the  disease  is  completed^ 
all  important  questions  affecting  the  vital  interests  of  the  patient 
have  been  answered  ;  adhesions  have  been  severed,  important  vessels 
controlled,  intestinal  complications  dealt  with,  and  tumors  developed 
in  situations  difficult  of  access  have  been  removed.  In  other  words^ 
those  factors  in  the  case  which  often  demand  an  alert  judgment  and 
the  highest  surgical  skill  have  all  been  dealt  with ;  the  rest  of  the 
operation,  closing  the  pelvic  wound  and  the  abdominal  incision,  fol- 
lows a  certain  routine  which  may  with  safety  be  left  in  the  hands  of 
a  well-trained  assistant. 

''  {b)  Complications  met. — I  have  insisted  particularly  upon  the 
novel  way  in  which  serious  complications  are  simplified  by  this  plan 
of  treatment,  and  I  would  refer  chiefly  to  two  kinds  of  complica- 
tions : 

"  First,  fibroid  tumors  located  under  the  peritonseum  of  the  pel- 
vic floor ;  and, 

"  Second,  inflammatory  masses  situated  behind  the  broad  liga- 
ments, with  dense  adhesions  to  the  pelvic  peritonseum,  to  the  rec- 
tum, and  often  to  the  small  intestines. 

"  In  the  case  of  the  subpelvic  peritoneal  fibroids,  it  is  astonishing 
how  difficult  they  are  to  get  at  from  above,  and  how  easily,  on  the 
other  hand,  they  roll  out  when  handled  from  beneath  by  this  pro- 
cedure. 

"  I  would  say  the  same  of  the  inflammatory  cases.  Matted  masses 
adherent  in  all  directions  which  resist  enucleation  from  above  are 
often  removed  with  ease  when  rolled  up  from  the  pelvic  floor  from 
below.  The  adherent  structures  seem  to  be  unrolled  in  a  natural 
and  easy  way,  in  surprising  contrast  to  the  difficulties  experienced 
and  the  injuries  inflicted  in  gaining  the  slightest  finger-hold  in  pro- 
ceeding from  above. 

"  To  recapitulate :  Abdomirial  hysterectomy  by  the  continuous 
incision  down  through  one  broad  ligament  across  cervix  and  up 
through  the  other  broad  ligament,  is  contrasted  with  hysterectomy 


FIBROMA  OF  THE   UTERUS.  381 

lay  an  incision  down  to  the  cervix  through  one  broad  figaraent,  and 
then  down  througli  the  other,  followed  by  amputation  of  the  cervix. 

"  The  special  advantages  offered  by  this  method  of  operating  are : 

"  1.  The  saving  of  from  sixtj^  to  eighty  per  cent  of  the  time  in 
the  enucleating  stage  of  operation. 

"  2.  The  ease  with  which  intra-ligamentary  myomata  and  myo- 
mata  beneath  the  pelvic  peritonaeum  may  be  enucleated. 

"  3.  The  ease  with  which  inflammatory  masses  posterior  to  the 
broad  ligament  may  be  enucleated  by  attacking  them  from  below 
after  dividing  the  cervix. 

"4.  The  control  of  a  displaced  ureter,  on  the  side  last  opened 
up,  keeping  it  out  of  the. way  of  injury  by  the  simple  mechanism 
of  the  operation.'' 

Traction  and  Morcellation. — Dr.  Emmet,  I  believe,  was  the  first 
to  operate  by  the  method  which  he  calls  traction  and  morcellation, 

lutra-uterine  tumors  that  have,  in  the  progress  of  expulsion,  di- 
lated the  cervix,  but  are  sessile — that  is,  attached  to  the  uterus  by  a 
broad  base — should  be  removed,  be  enucleated.  That  operation  is 
performed  as  follows :  The  patient  is  placed  in  Sims's  position  or  in 
the  lithotomy  position,  according  to  the  preference  of  the  operator, 
and  the  parts  exposed.  The  capsule  is  divided  at  the  presenting 
portion  of  the  tumor  with  the  knife,  or,  if  very  vascular,  with  the 
cautery.  The  tumor  is  seized  with  a  double  tenaculum  forceps,  and, 
while  making  traction,  the  tumor  is  separated  from  its  attachments 
by  enucleation.  A  variety  of  instruments  have  been  invented  and 
used  for  enucleating,  but  I  have  found  most  of  them  poorly  adapted 
to  the  purpose.  I  use  with  satisfaction  the  dry  dissector,  well  known 
in  general  surgery,  but  made  larger  and  longer.  The  blades  are 
wedge-shaped  and  rounded  on  the  sides,  and  one  is  blunt  and  the 
other  provided  with  very  fine  saw  teeth. 

The  blunt  blade  or  end  of  the  instrument  is  used  in  operating 
upon  hard  tumors  when  the  capsule  is  easily  separated.  The  blade 
with  the  teeth  is  required  when  the  capsule  is  more  firmly  attached 
to  the  tumor.  It  is  always  easier  and  better  to  enucleate  the  tumor 
in  mass,  and  yet  when  one  is  too  large  for  this  it  can  be  reduced  by 
morcellation.  Having  completed  the  enucleation,  the  capsule  should 
be  removed  if  it  does  not  retract  but  remains  dangling  in  the  cavity 
of  the  uterus.  That  is  done  by  gathering  together  the  edges  of  the 
opening  at  its  lower  part,  seizing  it  in  a  forceps,  twisting  it,  and  then 
passing  the  wire  loop  around  its  upper  portion  and  removing  it  with 
the  ecraseur. 

This  is  a  most  important  part  of  the  operation.     If  the  capsule 


382  ■  DISEASES   OF   WOMEN. 

is  left  it  may  slough,  and  give  much  trouble.  Again,  packing  suffi- 
cient for  drainage  is  used.  This  part  of  the  operation  should  be 
done  quickly,  because  the  uterus  contracts  in  time  and  makes  it  diffi- 
cult to  place  the  packing. 

ILLUSTRATIVE    CASES. 

Fibroma  of  the  Uterus ;  Recovery  without  Treatment. — This  case 
illustrates  a  class,  not  by  any  means  large,  in  which  the  disease  runs 
its  course  without  causing  much  discomfort  or  impairing  the  health 
to  any  great  extent,  and  without  being  influenced  by  treatment. 
The  patient  was  highly  nervous  and  very  active,  had  a  good  consti- 
tution, and  enjoyed  good  health.  When  she  was  about  thirty  years 
old  her  menstrual  flow  became  more  free  than  formerly.  She  had 
up  to  that  time  been  quite  regular  and  normal  in  regard  to  menstru- 
ation. This  slight  menorrhagia  continued,  and  occasionally  was  quite 
profuse.  She  also  had  backache  and  pelvic  tenesmus,  which  rendered 
her  less  active  and  enduring  than  in  her  earlier  life.  I  flrst  saw  her 
professionally  when  she  was  thirty-one  years  of  age.  She  was  then 
single  and  enjoying  fair  health.  I  supposed  that  she  might  have  a 
fibroma  of  the  uterus  from  the  history,  and  suggested  that  I  should 
find  out  by  examination  the  exact  condition.     This  she  objected  to. 

From  this  onward  she  continued  about  the  same.  The  menor- 
rhagia continued,  and  she  had  at  times  dysmenorrhoea  and  leucor- 
rhoea,  but  all  of  these  did  not  impair  her  health  or  usefulness  suf- 
ficiently to  make  her  willing  to  submit  to  treatment.  At  forty 
years  of  age  she  married,  and  then  her  symptoms  increased  consid- 
erably, but  in  the  intermenstrual  periods  she  was  fairly  well.  Four 
years  after  her  marriage  she  had  an  attack  of  malarial  fever  of  a  mild 
order,  and  then  the  menorrhagia  and  dysmenorrhoea  became  worse, 
and  I  then  had  an  opportunity  to  examine  her,  and  found  that  there 
was  a  fibroma  in  the  posterior  wall  of  the  uterus,  probably  inter- 
stitial. She  soon  recovered  from  the  malaria  and  its  effects,  and 
then  her  uterine  troubles  became  as  the}"  had  been  formerly.  About 
this  time  I  made  an  application  of  iodine  to  the  cavity  of  the  uterus, 
but  as  she  improved  she  did  not  return  for  further  treatment.  I 
saw  her  occasionally  while  visiting  other  members  of  her  family,  and 
heard  that  she  was  about  the  same  as  formerly. 

According  to  her  own  statement,  she  was  not  at  any  time  quite 
well,  but  not  ill  enough  to  be  willing  to  be  treated.  When  she  was 
forty-nine  she  again  consulted  me,  and  I  then  found  that  the  men- 
strual flow  had  been  diminished  for  over  one  year,  and  had  been  ab- 
sent altogether  for  three  months.     She  was  quite  nervous  and  resf; 


FIBROMA  OF  THE  UTERUS.  383 

less,  just  as  many  are  at  the  menopause.  I  examined  tlie  uterus, 
and  found  that  the  fibroma  had  almost  disappeared.  The  uterus 
was  much  larger,  at  least  twice  as  large  as  it  should  be  after  the 
menopause,  but  not  one  third  the  size  that  it  was  when  I  first  ex- 
amined the  case.  I  have  seen  her  since,  and  find  that  she  is  quite 
well. 

Interstitial  Fibroma  of  Large  Size,  complicated  with  Endometritis ; 
treated  by  Tincture  of  Iodine  to  the  Endometrium,  Ergot  during  the 
Menstrual  Period,  and  Mild  Continuous  Current  of  Electricity. — A 
strong  and  vigorous  lady  who  had  always  enjoyed  good  health  until 
after  she  was  twenty-five  years  old,  was  first  seen  when  she  was 
thirty-one.  She  was  married  at  twenty-six,  and  soon  thereafter 
began  to  menstruate  too  freely ;  she  never  was  pregnant.  When 
first  seen  she  was  prostrated  with  a  severe  menorrhagia.  I  then  ob- 
tained the  facts  given  above,  and  also  learned  that  she  had  sufliered 
from  pelvic  pain,  leucorrhoea,  backache,  and  a  gradually  increasing 
menstrual  flow  until  the  time  I  saw  her,  when  she  was  quite  ex- 
hausted. The  uterus  and  tumor  extended  upward  to  half-way  be- 
tween the  pubes  and  umbilicus.  Stimulants  and  ergot  were  given, 
but  the  flow  continued,  and  then  the  tampon  was  used,  which  stojjped 
it.  She  improved  from  this  time,  quite  perceptibly,  but  was  pulled 
down  at  the  next  period,  though  not  to  so  low  a  point  as  before.  She 
was  then  put  under  treatment  for  the  endometritis.  The  hot-water 
douche  was  tried,  and  the  whole  endometrium  touched  with  tincture 
of  iodine.  In  order  to  do  this  it  was  necessary  to  dilate  the  os  exter- 
num, and  then  by  using  the  pipette,  the  application  could  be  made 
very  thoroughly.  There  was  at  first  considerable  catarrh  of  the  cer- 
vix, and  for  that  a  few  applications  of  tincture  of  iodine  and  carbolic 
acid,  equal  parts,  were  made.  Under  this  treatment  the  menstrual 
flow  became  less  free,  although  the  tumor  increased  slightly  in  size. 
After  remaining  under  treatment  intermittently  for  about  two  years, 
she  was  induced  to  place  herself  under  the  care  of  a  physician  who 
made  the  acquaintance  of  her  husband.  This  gentleman  treated  her 
twice  a  week  with  a  mild  continuous  current  of  electricity,  which  he 
passed  through  the  tumor  by  placing  one  electrode  upon  the  ab- 
domen and  the  other  upon  the  back. 

Three  quarters  of  a  year  were  occupied  in  this  way,  but  without 
any  improvement ;  she  neither  gained  nor  lost,  except  that  her  flow 
was  more  free.  She  returned  to  my  care  again,  and  I  resumed  the 
treatment  of  the  endometritis  with  iodine ;  I  also  continued  the  elec- 
tricity, but  did  so  by  procuring  a  battery  for  the  patient,  and  having 
one  of  my  assistants  teach  her  how  to  use  it.     In  place  of  applying 


384  DISEASES  OF  WOMEN. 

it  twice  a  week,  as  the  doctor  had  done,  she  used  it  every  day,  and  I 
am  satisfied  that  she  used  it  as  effectually  as  the  doctor. 

This  treatment  was  kept  up  for  two  years.  Whenever  her  menses 
became  very  free,  or  if  the  leucorrhoea  returned,  she  came  for  treat- 
ment, otherwise  she  used  the  electricity  alone.  The  tumor  had 
diminished  perceptibly,  but  her  general  improvement  was  out  of 
proportion  to  local  changes,  excepting  that  the  endometritis  was  re- 
lieved. After  this  she  went  to  live  in  the  country,  and  was  not  seen 
again  until  she  was  forty -six  years  old.  I  then  found  that  the 
menses  were  normal,  and  that  the  tumor  was  very  much  reduced. 
When  first  seen,  I  could  with  ease  introduce  the  sound  into  the 
uterus  seven  and  a  half  inches,  while  at  the  age  of  forty-six  the 
cavity  of  the  uterus  measured  less  than  four  inches. 

Interstitial  Fibroma  of  the  Uterus  treated  with  Ergot ;  Eecovery. 
— This  patient  was  thirty-four  years  old,  married,  and  had  one  child 
when  she  was  twenty-three  years  old.  After  its  birth  she  suffered 
from  leucorrhoea  and  backache,  but  did  not  have  any  treatment  until 
she  was  twenty-seven  years  of  age.  She  then  began  to  menstruate 
too  freely,  and  was  treated  by  her  physician,  but  without  effect. 
The  menorrhagia,  while  it  depressed  her,  did  not  disable  her  alto- 
gether, so  she  went  about  her  duties  until  she  noticed  a  tumor  in  the 
abdomen  ;  she  then  came  to  me  for  advice.  I  found  the  uterus  en- 
larged, extending  upward  to  within  two  inches  of  the  umbilicus. 
The  cavity  of  the  uterus  was  detiected  to  the  right  and  backward, 
and  the  sound  passed  to  the  depth  of  seven  inches.  The  fibroma 
occupied  the  left  anterior  wall  and  projected  considerably  to  the 
left,  giving  to  the  whole  mass  (uterus  and  tumor)  an  irregular  out- 
line. 

There  was  some  endometritis,  and  the  patient  was  slightly  anae- 
mic, but  otherwise  her  health  was  good.  Half  a  drachm  of  fluid 
extract  of  ergot  was  given  before  meals,  for  about  a  month,  in  the 
hope  that  it  might  incline  the  tumor  toward  the  cavity  of  the 
uterus,  and  by  partially  expelling  it  bring  it  within  reach  for  the 
operation  of  enucleation.  At  the  end  of  a  month  there  was  no 
change  in  the  position  of  the  tumor ;  ergot  was  then  used  hypoder- 
mically  about  twenty  minims  every  third  day.  This  excited  strong 
uterine  contractions,  which  lasted  for  about  an  hour  or  more  each 
time.  This  treatment  was  continued  for  three  weeks,  but  without 
changing  the  position  of  the  tumor,  though  it  diminished  in  size. 
The  hypodermic  use  of  the  ergot  was  then  given  up,  because  the 
patient  became  tired  of  the  pain  it  caused.  She  continued  to  take 
the  quantity  first  given  by  tlie  mouth  for  seven  or  eight  weeks,  and 


FIBROMA  OF  THE  UTERUS.  385 

the  tumor  continued  to  decrease  in  size.  The  hypodermic  use  of  the 
ergot  was  tried  again  for  nearly  a  month,  but  was  only  used  every 
fourth  day.  At  the  end  of  three  months  all  treatment  was  stopped 
because  the  patient's  digestion  became  impaired.  She  was  kept 
upon  tonic  treatment  for  a  time  until  her  general  condition  improved, 
and  again  the  ergot  was  resumed,  using  it  hypodermically  and  by 
the  mouth  alternately.  The  menorrhagia  gradually  subsided,  and  at 
the  end  of  six  months  the  tumor  had  diminished  over  two  thirds  of 
its  former  size.  The  cavity  of  the  uterns  was  only  three  and  three 
quarter  inches  in  depth.  No  further  treatment  was  deemed  neces- 
sary. Three  years  after  the  treatment  was  suspended  the  patient 
was  in  good  health,  and  her  menses  were  regular. 

The  uterus  was  above  the  average  size,  but  not  much  so.  The 
left  wall  was  more  than  twice  the  thickness  of  the  other,  so  that 
there  was  a  trace  of  the  fibroma  remaining,  but  it  was  harmless. 
"While  the  object  for  which  the  ergot  was  originally  given  was  not 
attained  a  happier  result  followed. 

The  ergot  so  influenced  the  nutrition  of  the  growth  as  to  cause 
dropsy.  This  is  a  rare  effect  of  ergot,  and  yet  it  sometimes  is  pro- 
duced in  certain  cases. 

Submucous  Fibroma ;  Expulsion  by  the  Natural  Efforts ;  Separation 
of  the  Pedicle  with  the  Ecraseur ;  Recovery. — The  patient  was  un- 
married and  thirty-five  years  old ;  she  was  large,  strong,  and  had 
always  had  good  health.  She  began  to  menstruate  at  fourteen,  and 
continued  to  do  so  in  a  perfectly  normal  way  until  she  was  twenty- 
eight  years  old.  At  that  time  the  menstrual  flow  became  more  free 
and  lasted  a  little  longer.  From  this  time  onward,  the  menstrual 
flow  gradually  but  not  regularly  increased,  until  she  established  a 
well-marked  menorrhagia.  This  undermined  her  health  consider- 
ably. She  lost  flesh,  and  became  quite  anaemic.  She  had  charge  of 
a  branch  of  a  large  business  establishment,  and  was  an  efficient  and 
trusted  employe,  but  her  duties  became  very  trying  to  her,  espe- 
cially  at  her  menstrual  periods,  at  which  times  she  was  obliged  to 
stay  at  home  occasionally.  Still  she  persisted  in  her  work  until  she 
was  taken  ill  and  confined  to  her  bed.  She  called  in  a  poorly-quali- 
fied physician  who  failed  to  relieve  her  ;  subsequently  her  employer 
requested  me  to  take  her  in  charge.  I  found  the  uterus  enlarged 
from  the  pressure  of  a  fibroma,  which  was  evidently  intra-uterine. 
She  also  had  all  the  signs  and  symptoms  of  a  pelvic  cellulitis  in  the 
left,  broad  ligament.  This  terminated  in  resolution,  and  in  about 
two  weeks  she  was  able  to  be  around  again.  Although  still  weak, 
she  returned  to  her  duties,  but  her  menorrhagia  continued.     Every 

20 


386  DISEASES  OF  WOMEN. 

effort  was  made  by  tonics  and  good  food  to  improve  her  strength. 
She  was  requested  to  rest  at  her  menstrual  periods,  and  to  take  ergot 
and  cannabis  Indica  in  moderate  doses  at  such  times.  She  con- 
tinued to  be  quite  anaemic,  but  dragged  along  with  her  work  as 
best  she  could.  I  saw  her  only  occasionally,  and  found  that  the 
tumor  did  not  grow  very  fast,  and  she  did  not  lose  much  in  general 
strengtli.  This  went  on  for  six  years,  when  she  began  to  have  se- 
vere pains  from  uterine  contractions ;  for  this  I  saw  her  and  sug- 
gested that  she  should  give  up  the  use  of  ergot.  I  did  not  see  her 
again  for  about  five  months,  when  I  was  called  in  haste  to  her,  and 
found  her  suffering  from  great  expulsive  pains.  She  told  me  that 
it  was  time  for  her  to  menstruate,  but  she  had  had  very  little  flow, 
but  instead  these  extreme  j^ins.  Examining  the  abdomen,  I  found 
that  the  size  of  the  uterus*  was  greatly  increased,  and  that  in  the 
absence  of  uterine  contractions,  there  was  distinct  fluctuation  at  the 
upper  third  of  the  uterus.  I  presumed  that  the  fluctuating  mass 
was  a  cyst  which  had  rapidly  developed  since  the  time  that  I  had 
seen  her  before.  On  making  a  vaginal  examination,  I  found  the 
cervix  dilated  about  two  inches  and  a  solid  fibroma  protruding  at  the 
OS  externum.  Opium  was  given  to  ease  the  pain  which  was  ex- 
hausting her,  and  at  the  end  of  twelve  hours  I  found  that  although 
the  pains  had  modified  a  little,  they  had  continued.  The  dilatation 
of  the  cervix  had  progressed.  The  opium  was  continued  in  large 
doses.  It  was  then  night,  and  I  desired  her  to  sleep.  The  night 
was  passed  fairly  well,  she  had  pains,  but  slept  between  them.  Next 
day  the  opium  was  suspended  and  the  pains  returned  with  renewed 
vigor.  Toward  evening,  after  having  several  violent  pains,  they 
ceased,  but  were  followed  by  the  most  distressing  pressure  upon 
the  rectum  and  bladder.  There  was  no  cessation  to  this  suffering, 
and  I  was  called  in  haste  to  see  her.  I  found  the  tumor  the  size  of 
a  fetal  head,  pressing  upon  the  perinseum  and  firmly  impacted  in 
the  pelvis.  The  fluctuating  mass  was  still  felt  in  the  pelvis  but 
lower  down.  Her  sufferings  were  such  from  the  complete  obstruc- 
tion of  the  rectum  and  bladder  that  immediate  relief  was  de- 
manded. 

She  was  at  once  conveyed  to  a  private  room  in  the  hospital,  and 
the  removal  of  the  tumor  effected.     The  operation  was  as  follows : 

It  was  impossil)le  to  determine  the  location  or  character  of  the 
attachment  of  the  tumor,  nor  could  I  pass  the  chain  of  the  ecraseur 
over  it,  so  firmly  was  it  fixed  in  the  vagina.  To  avoid  incision  of 
the  pelvic  floor  and  delivery  of  the  tumor  en  masse — a  very  bad 
method  which  has  been  practiced — I  determined  to  diminish  the 


FIBROMA  OF  THE  UTERUS.  38Y 

size  of  tliG  mass  bj  exsection  with  tlie  scissors  and  forceps.  It  was 
nic^lit,  so  I  liad  to  use  artificial  light  reflected  from  the  head-mirror. 
Through  Sims's  speculum  it  was  easy  to  cut  away  enough  to  enaljle 
me  to  determine  that  the  pedicle  was  not  large,  and  that  the  chain 
of  the  ecraseur  could  be  passed.  While  making  this  examination, 
and  also  while  adjusting  the  chain,  there  was  considerable  discharge 
of  dark  blood  from  above  the  tumor.  The  pedicle  was  easily  di- 
vided, and  the  remains  of  the  tumor  were  further  reduced,  so  that 
it  could  be  brought  through  the  vulva  without  laceration.  The  re- 
moval of  the  mass  was  followed  by  a  gush  of  dark  blood,  at  least 
a  pint  in  all,  and  there  were  several  clots  which  remained  in  the 
vagiua.  These  were  raj)idly  removed,  and  then  I  could  see  the 
distended  and  empty  uterus.  The  blood  had  accumulated  in  the 
uterus  above  the  tumor,  and  given  rise  to  the  fluctuation  and  rapid 
increase  in  the  size  of  the  uterus  which  I  had  observed. 

"With  the  hght  reflected  from  the  head-mirror  I  was  able  to  ex- 
amine the  entire  cavity  of  the  uterus  most  thoroughly.  By  holding 
the  lips  of  the  os  externum  apart  with  an  elevator  and  sponge-holder, 
the  view  of  the  interior  of  the  uterus  was  complete.  The  site  of 
the  attachment  of  the  tumor  could  be  clearly  seen,  and  the  gradual 
contraction  of  the  uterus  was  also  noted. 

There  was  nothing  of  interest  in  the  after-history  of  the  case. 
The  patient  made  a  good  recovery,  and  gradually  regained  her  health 
and  strength.  It  is  now  four  years  since  the  operation,  and  she  has 
continued  in  perfect  health. 

Uterine  Fibroma,  supposed  to  be  a  Uterine  Fibro-Cyst ;  Death  from 
Septicaemia  during  the  Process  of  Expulsion. — An  unmarried  lady  of 
somewhat  delicate  organization  came  under  my  observation  when 
she  was  thirty  years  of  age ;  she  said  that  five  years  previously  she 
began  to  suffer  from  menorrhagia,  and  soon  afterward  began  to  ob- 
serve a  gradual  increase  in  the  size  of  the  abdomen.  When  first 
seen,  the  tumor  was  about  the  size  of  the  uterus  at  the  seventh 
month  of  gestation ;  all  the  physical  signs  of  a  submucous  fibroma 
were  obtained.  Her  general  health  was  somewhat  impaired,  she 
was  anaemic,  owing  to  the  menorrhagia,  which  was  not  excessive ; 
otherwise  she  was  in  fairly  good  health,  and,  as  her  circumstances 
in  life  were  good,  she  was  able  to  be  around  and  enjoy  life.  She 
was  placed  upon  a  general  tonic  treatment,  with  the  use  of  ergot  and 
cannabis  Indica,  which  were  given  at  the  menstrual  period.  She 
continued  for  three  years  to  do  fairly  well,  occasionally  having  an 
attack  of  menorrhagia,  which  pulled  her  down  a  little,  but  she  readily 
recovered  from  this,  and  went  about  in  her  usual  way. 


388  DISEASES  OP  WOMEN. 

She  was  seen  only  occasionally,  and  the  general  plan  of  treatment 
was  not  changed. 

About  the  fonrth  year  after  she  came  mider  my  observation,  she 
had  an  attack  of  menorrhagia  which  was  rather  more  severe  than 
usual,  and  she  took  larger  doses  of  ergot,  and  continued  the  remedy 
longer  than  was  her  habit.  This  controlled  the  menorrhagia  but 
produced  severe  uterine  pain,  for  which  I  was  called  to  prescribe. 
I  then  carefully  examined  the  tumor  and  found  that  it  had  increased 
in  size  considerably  from  the  time  1  had  seen  her  before — about  four 
or  five  months.  I  found  that  the  upper  portion  of  the  tumor  was 
quite  elastic,  and  that  there  was  distinct  fluctuation  extending 
through  an  area  of  about  five  inches.  I  then  suspected  a  fibro- 
cyst. 

Soon  after  this  she  was  seen  by  my  distinguished  friend,  Dr.  T.-G. 
Thomas,  who,  without  knowing  of  the  patient's  history  or  my  own 
opinion,  made  the  diagnosis  of  fibro-cyst.  During  the  remainder  of 
that  winter  and  the  next  spring  she  had  more  menorrhagia,  and  was 
kept  more  continually  under  the  influence  of  ergot;  when  summer 
came  she  had  regained  some  of  her  former  strength,  and  went  to  the 
country,  where  she  remained  for  several  months.  She  returned  in 
the  autumn  slightly  improved,  but  about  a  month  afterward  began 
to  suffer  from  severe  pains,  due  to  uterine  contractions.  These  pains 
increased  in  severity  and  frequency,  until  she  was  unable  to  leave 
her  room.  She  then  sent  for  me,  when  to  my  surprise  I  found  the 
cervix  uteri  fully  dilated  and  the  tumor  partially  expelled  from 
the  utenis,  occupying  and  completely  fiUing  the  vagina.  The  ergot 
was  suspended,  and  she  was  relieved  from  her  severe  pain  by  the 
use  of  opium,  but  the  pressure  upon  the  pelvic  organs  became  so 
great  that  it  was  necessary  to  try  and  relieve  her.  The  lower  por- 
tion or  capsule  of  the  tumor  began  to  slough,  and  I  then  determined 
to  remove  all  of  the  tumor,  or  as  much  of  it  as  possible.  In  the 
mean  time  the  uterus  as  examined  through  the  abdominal  wall 
had  not  diminished  very  much  in  size,  and  the  fluctuation  was  more 
marked  and  more  extensive.  She  was  at  this  time  very  anaemic,  and 
so  weak  that  I  dared  not  anaesthetize  her.  So  I  proceeded  without 
doing  so,  with  the  patient  in  Sims's  position,  and  with  the  aid  of 
Sims's  speculum  I  rapidly  removed  all  that  portion  of  the  tumor 
which  occupied  the  vagina,  using  the  tenaculum  forceps  and  ha?rao- 
static  scissors.  There  was  very  little  haemorrliage,  and  the  patient 
derived  very  great  relief  from  the  removal  of  this  portion.  She  wap 
permitted  to  rest  for  a  few  days  and  ergot  was  again  given,  which 
produced  expulsion  of  another  mass  about  as  large  as  the  one  that 


FIBROMA  OF  THE  UTERUS.  389 

had  been  expelled,  this  was  removed  in  the  same  waj  as  the  other  5 
while  removing  a  portion  which  extended  up  into  the  cervix  uteri, 
about  five  or  six  ounces  of  lluid  escaped  from  the  cavity  of  the 
uterus.  Immediately  after  this  it  was  found  that  the  fluctuation  was 
greatly  lessened,  and  the  size  of  the  tumor,  as  observed  through  the 
abdominal  walls,  had  markedly  diminished.  She  had  after  this  con- 
siderable fever  and  disturbance  of  the  stomach,  and  this,  along  with 
her  marked  anaemia,  prostrated  her  so  that  nothing  could  be  done 
for  nearly  a  week  but  to  sustain  her.  At  the  end  of  that  time  her 
temperature  diminished  somewhat,  she  was  able  to  take  nourishment 
and  stimulants,  and  as  considerable  more  of  the  tumor  had  been  ex- 
pelled, a  third  attempt  was  made  to  remove  it.  I  was  able  to  re- 
move all  that  portion  outside  of  the  cervix ;  I  then  endeavored  to 
remove  a  portion  that  was  still  within  the  grasp  of  the  cervix ;  as 
soon  as  I  did  this,  about  four  ounces  of  putrid  matter  w^re  discharged 
from  the  uterus.  Although  there  was  not  much  haemorrhage,  and 
the  patient  did  not  complain  of  pain,  she  was  so  much  exhausted  and 
her  pulse  was  so  feeble  that  I  was  obliged  to  desist,  feeling  confident 
that  if  I  undertook  to  remove  the  remainder  of  the  tumor,  the 
patient  would  succumb.  The  cavity  of  the  uterus  was  carefully 
washed  out  with  carbolized  water,  and  the  patient  put  to  bed  and 
stimulated  and  nourished  as  well  as  possible.  Two  days  afterward, 
when  she  had  rallied  considerably,  I  found  that  the  lower  por- 
tion of  the  cervix  had  contracted  around  the  tumor,  and  that  it  was 
breaking  down  and  decomposing.  I  thoroughly  and  repeatedly 
washed  out  the  inner  cavity  of  the  uterus,  and  hoped  by  so  doing  to 
control  the  septicaemia  from  which  she  was  suffering  in  a  most 
marked  degree.  I  also  felt  confident  that  if  I  could  bring  her 
strength  up  again  that  I  might  be  able  to  remove  the  whole  of  the 
tumor.  But  this  proved  to  be  impossible,  although  the  uterus  con- 
tracted again,  in  fact,  sufiiciently  expelled  the  tumor  to  partially 
dilate  the  cervix.  She  at  no  time  was  in  any  condition  to  bear  so 
formidable  an  operation  as'  completing  the  enucleation  of  the  tumor. 
The  septicaemia  still  proceeded,  and  she  died  about  five  years  from 
the  time  that  she  first  came  under  my  observation. 

On  post-tnortem  examination  it  was  found  that  a  portion  of  the 
fibroma  as  large  as  a  fetal  head  remained,  and  was  attached  at  the 
posterior  and  right  lateral  wall  of  the  uterus,  and  that  it  closed  the 
cavity  very  thoroughly  by  pressure,  and  that  there  was  still  a  little 
fluid  in  the  fundus  uteri.  It  was  clearly  evident  from  this,  that  this 
obstruction  of  the  canal  below  and  the  distention  of  the  cavity  of 
the  uterus  above,  which  gave  rise  to  the  fluctuation  obtained  at  her 


390  DISEASES  OF  WOMEN. 

examination,  explained  the  resemblance  of  the  physical  signs  to  those 
obtained  in  the  uterine  libro  cysts. 

It  is  a  number  of  years  since  this  case  came  under  my  observa- 
tion, and  I  am  satisfied  that  had  I  known  then  as  much  as  I  know 
now  about  the  management  of  such  cases  I  should  probably  have 
been  able  to  save  her.  As  it  is,  I  still  think  that  had  she  sent  for  me 
when  she  returaed  from  the  country,  and  before  her  strength  became 
so  much  exhausted  from  the  efforts  at  expulsion,  I  might  have  been 
able  to  remove  the  whole  of  the  tumor ;  but  it  was  otherwise. 

A  Case  of  Submucous  Fibroma  m  which  Pregnancy  progressed  to 
Full  Time,  and  the  Tumor  was  completely  expelled  about  a  Week 
after  Confinement. — This  case  was  seen  in  consultation  with  Dr. 
Bodkin,  who,  when  called  to  attend  her  in  confinement,  found  a 
soHd  tumor  which  so  completely  filled  the  pelvis  that  he  could  not 
reach  the  os  'uteri.  The  labor-pains  continued,  the  membranes 
ruptured,  and  the  cord  became  prolapsed.  The  tumor  was  recognized 
as  a  fibroma  which  extended  down  into  the  cervix  and  at  the  same 
time  upward  toward  the  fundus.  It  was  a  long,  naiTOW  tumor  which 
may  have  assumed  that  shape  by  stretching  during  the  growth  of 
the  pregnant  uterus. 

We  agreed  to  try  to  deliver  by  version.  Accordingly,  when  the 
patient  was  anaesthetized  the  doctor  succeeded  in  pushing  up  the 
tumor  out  of  the  pelvis,  and  passing  his  hand  past  the  tumor  and 
through  the  os,  which  was  quite  dilatable,  he  turned  and  delivered. 

I  then  took  charge  of  the  placenta,  which  was  retained  for  some 
time.  To  facilitate  its  delivery  and  at  the  same  time  to  investigate 
the  tumor,  I  passed  my  hand  into  the  uterus  and  was  able  to  make 
out  by  bimanual  touch  the  size  and  location  of  the  tumor.  It  was 
oblong,  as  already  stated,  and  situated  in  the  anterior  wall  a  little  to 
the  left  side,  and  extended  from  the  cervix  nearly  to  the  fundus, 
and  evidently  was  immediately  beneath  the  mucous  membrane. 

The  patient  did  very  well  considering  all  things ;  she  had  con- 
siderable hsemorrhage  at  the  time,  and  the  discharge  afterward  was 
free  and  at  times  offensive,  and  she  had  long-continued  after-pains. 

About  seven  or  eight  days  after  her  confinement  she  had  an  at- 
tack of  tenesmus,  and  in  the  hope  of  obtaining  relief  she  got  up  to  the 
commode,  and  by  vigorous  expulsive  efforts  expelled  the  tumor.  It 
was  much  shrunken,  no  doubt,  but  even  then  the  doctor  estimated 
that  it  was  about  seven  inches  in  length  and  three  inches  in  diam- 
eter.    She  subsequently  did  well. 

In  this  connection  it  may  be  stated  that  uterine  fibromata  cause 
sterility,  as  a  rule,  owing  perhaps  to  the  endometritis  which  is  usu- 


FIBROMA  OF   THE  UTERUS.  391 

ally  present,  and  when  pregnancy  takes  place  miscarriage  generally 
occurs.  Still,  I  have  seen  at  least  four  cases  that  went  to  full  time. 
In  all  except  the  one  recorded  above  the  tumors  were  subperitoneal 
and  not  large. 

Extreme  Dilatation  of  the  Cervix  Uteri  and  Expulsion  of  a  Sub- 
mucous Fibroma  while  only  Slightly  Pedunculated;  The  Case  diag- 
nosticated as  Inversion  of  the  Uteras;  Operation  and  Recovery. — 
This  patient  came  to  my  hospital  clinic  and  gave  a  history  of  menor- 
rhagia  for  years,  and  for  several  months  past  a  metrorrhagia  and 
uterine  pain.  She  was  quite  anaemic,  but  had  always  been  w^ell  and 
strong  until  the  excessive  menstruation  came.  She  also  stated  that 
she  visited  the  outdoor  department  of  the  Woman's  Hospital  of  Kew 
York,  and  the  gentleman  who  saw  her  said  that  her  womb  was 
turned  inside  out,  that  she  should  enter  the  hospital  for  operation, 
and  that  her  case  was  a  dangerous  one. 

I  presumed  that  the  diagnosis  made  was  inversion  of  the  uterus, 
and  on  asking,  the  doctor  about  the  case  he  told  me  that  he  beheved 
it  to  be  so.  On  my  first  examination  I  found  a  tumor  in  the  va- 
gina which,  in  size  and  shape,  was  exactly  like  an  inverted  uterus. 
The  mass  was  covered  with  uterine  mucous  membrane.  Absence 
of  the  fundus  and  body  of  the  uterus  in  the  upper  part  of  the  pel- 
vis was  observed  by  the  bimanual  touch.  That  portion  of  the  mass 
which  was  uppermost  was  larger  than  that  which  is  usually  found 
in  inversion  of  the  uterus,  but  in  the  center  of  it  there  was  a  slight 
depression  which  is  generally  found  in  inversion.  Passing  the 
sound  around  the  tumor  gave  evidence  that  the  vagina  was  at- 
tached to  the  upper  part  of  the  tumor,  but  by  pressing  the  tumor 
to  one  side  and  separating  the  vagina  from  it,  I  could  see  that  there 
was  uterine  mucous  membrane  above  the  vagina,  which  extended 
upward,  inward,  and  over  the  tumor.  By  seizing  the  tumor  and 
twisting  it  round  upon  its  axis,  I  also  observed  that  the  upper  part 
of  the  vagina  did  not  move  with  it  as  would  have  been  the  case  if 
there  had  been  inversion  of  the  uterus.  From  these  signs  I  con- 
cluded that  the  tumor  was  a  fibroma,  with  a  small  but  very  short 
pedicle  attached  to  the  fundus  uteri,  and  that  the  cervix  and  lower 
portion  of  the  uterus  were  so  completely  dilated  that  the  vaginal 
and  uterine  walls  were  continuous. 

I  presume,  that  in  time,  the  tumor  would  have  dragged  the  fun- 
dus uteri  downward  and  produced  inversion.  This  has  occurred. 
In  fact,  it  is  not  an  unusual  thing  to  find  a  partial  inversion  of  the 
uterus  caused  by  fibromata  during  their  expulsion. 

The  pedicle  was  divided  with  the  ecraseur  and  the  tumor  re- 


392  DISEASES  OF  WOMEN. 

moved.  The  cavity  of  tlie  uterus  then  appeared  like  a  cup-shaped 
dome  at  the  termination  of  the  vagina.  A  sjDonge,  in  a  holder,  was 
gently  pressed  against  the  fundus  uteri,  and  held  there  until  the 
uterus  contracted^  which  it  did  quite  slowly.  This  was  done  to  pre- 
vent a  possible  inversion  from  taking  place.  The  j^atient  recov- 
ered very  promptly. 

Soft  Fibroma ;  Atrophy  of  the  Muscular  "Wall  of  the  Uterus  at  the 
Point  of  Attachment  of  the  Tumor ;  Enucleation  after  Dilatation  of  the 
Cervix  Uteri  and  Partial  Expulsion;  Recovery. — The  patient  was 
forty-nine  years  old,  married,  and  had  had  two  children,  the  last  one 
sixteen  years  before  the  time  when  she  came  under  my  care.  She 
was  a  strong,  healthy  lady,  and  had  been  wel.  until  she  was  about 
forty-live  years  of  age.  At  that  time  she  began  to  menstruate  more 
freely  than  at  any  previous  time  in  her  life,  but  being  told  that  it  was 
due  to  "  change  of  life  "  she  did  nothing  for  it,  until  she  became  so 
weak  that  she  sought  advice  of  a  practitioner  who  treated  her  locally 
for  ulceration  of  the  cervix  which  he  said  she  liad.  She  grew  worse, 
the  bleeding  was  more  free  and  lasted  longer  at  each  period,  and 
she  had  a  profuse  watery  discharge  at  other  times.  Then  uterine 
pains  came  on,  which  she  said  were  like  the  first  pains  of  labor. 
This  was  the  history  which  I  obtained  when  called  to  see  her  the 
first  time. 

On  examination  I  found  the  cervix  well  dilated,  and  part  of  a 
soft  fibroma  occupying  and  filling  the  upper  part  of  the  vagina. 
The  pressure  gave  her  much  discomfort,  and  I  found  that  the  por- 
tion in  the  uterus  was  quite  as  large  as  that  Avhich  occupied  the 
vagina.  Without  giving  the  patient  an  anaesthetic,  I  removed  all 
that  was  outside  of  the  uterus  with  the  ecraseur.  There  was  no 
pain  and  very  little  bleeding  caused  by  the  operation.  The  patient 
being  fatigued  by  remaining  in  Sims's  position  I  did  nothing  more 
for  two  days,  and  at  the  end  of  that  time  the  larger  part  of  the 
mass  was  expelled  from  the  uterus.  It  was  oblong  but  not  pedun- 
culated. All  that  was  protruding  from  the  os  externum  was  re- 
moved with  the  ecraseur,  and  the  stump  was  seized  with  a  double 
tenaculum  forceps  and  enucleated.  Traction  being  made  with  the 
forcejis  the  mass  was  separated  from  the  capsule  with  a  blunt  cu- 
rette. There  was  very  little  pain  caused  until  the  mass  was  sepa- 
rated all  round  and  the  deepest  attachment  w-as  reached.  Then  the 
patient  began  to  conij)lain.  This  was  fortunate,  because  it  made  me 
very  careful.  I  simply  made  steady  traction  and  counter-pressure 
with  the  curette.  When  the  mass  came  away  I  could  see  the  peri- 
tonaeum very  plainly  at  the  bottom  of  the  cavity.     My  assistant 


FIBROMA  OF  THE  UTERUS.  393 

also  observed  it,  and  recognizing  what  it  was,  lie  naturally  was  quite 
anxious.  A  space,  about  the  size  of  a  twentj-hve  cent  piece  was  ex- 
posed. It  had  not  been  wounded  at  all,  but  appeared  as  if  it  had 
separated  from  the  tumor  very  easily.  To  make  sure  that  there  was 
no  mistake  I  examined  by  the  touch  and  found  the  parts  exactly  as 
tliey  appeared  to  be  on  inspection. 

Submucous  Fibroma  of  Large  Size  extending  through  the  Uterine 
Wall  to  the  Peritonaeum ;  treated  first  by  Partial  Exsection  with  the 
Galvano-Cautery  and  Several  Years  after  by  Enucleation ;  Recovery. — 
This  was  a  hospital  case  which  I  saw  with  Dr.  Gushing.  The  tumor 
was  large,  and  extended  down  into  the  cervix  on  one  side  and  could 
be  easily  reached.  The  patient  was  suffering  greatly  from  bleed- 
ing. Partial  excision  was  made  by  passing  two  large  curved  needles 
through  a  section  of  the  tumor,  and  then  passing  the  wire  be- 
low the  needles,  and  cutting  it  off  by  heating  the  wire.  Section 
after  section  was  removed  in  this  way,  until  all  that  portion  which 
could  be  reached  conveniently  was  removed,  about  two  thirds  of  the 
whole,  perhaps.  The  operation  was  long,  and  I  did  not  think  it 
prudent  to  continue  the  efforts  to  remove  the  whole  mass.  Recov- 
ery from  the  operation  was  without  interruption,  and  the  patient 
was  much  improved.  The  menorrhagia  subsided,  she  gained  her 
former  strength,  and  was  able  to  make  her  living  as  a  laundress. 

In  a  few  years  the  tumor  had  grown  again,  and  all  the  old 
symptoms  returned  and  were  worse  than  ever.  Dr.  Gushing  had  to 
see  her  for  several  attacks  of  menorrhagia,  which  nearly  proved 
fatal.  She  then  came  into  the  hospital.  The  tumor  was  nearly  as 
large  as  it  was  before,  and  she  was  extremely  feeble  and  angemic. 
There  was  a  cardiac  mitral  murmur.  The  officers  of  the  hospital 
strongly  advised  that  I  should  not  operate,  and  I  would  have  gladly 
followed  their  advice,  but  the  patient  begged  that  I  should  try 
again  to  help  her,  and  I  agreed  to  do  so.  The  tumor  was  low  down 
in  the  pelvis  and  projected  beyond  the  opposite  side  of  the  cervix. 

Ether  was  given,  and  the  pulse  improved  a  little  under  its  influ- 
ence. The  capsule  was  divided  with  the  thermo- cautery,  and  sepa- 
rated from  the  tumor  over  its  exposed  portion.  A  strong  forceps 
was  fixed  in  the  mass,  and  while  strong  traction  was  being  made 
the  enucleation  was  performed  with  the  spoon-saw  of  Thomas. 
When  I  had  nearly  completed  the  separation,  I  noticed  that  there 
was  very  little  resistance  on  the  part  of  the  uterine  wall  at  the 
upper  part ;  I  then  made  a  bimanual  examination  and  found  that 
I  had  passed  through  the  muscular  coat  of  the  uterus  entirely. 
I  was  fearful  that  if   I  made  any  further  effort  to  complete  the 


394  DISEASES  OF  WOMEN. 

enucleation  I  might  wound  the  peritonaeum.  The  detached  por- 
tion was  separated  from  the  rest,  and  the  operation  stopped.  The 
portion  left  was  about  the  size  of  a  hen's  egg.  There  was  not 
much  bleeding,  but  I  can  only  saj  that  the  patient  was  living  when 
she  was  put  to  bed.  The  uterus  contracted  fairly  well.  There  was 
no  further  haemorrhage,  but  a  free  disci large  of  serum  continued  for 
a  number  of  days.  I  felt  sorry  that  I  had  not  been  able  to  remove 
the  whole  of  the  tumor,  but  was  glad  that  her  life  had  been  spared. 
She  improved  slowly  in  strength,  and  was  able  to  leave  the  hospital 
in  three  weeks.  The  heart-murmur,  which  was  presumed  to  be 
largely  due  to  her  extreme  anaemia,  proved  to  be  due  to  mitral  in- 
sufficiency, and  although  she  had  no  more  trouble  from  menorrhagia, 
she  did  not  fully  regain  her  strength.  She  took  up  her  old  occu- 
pation, but  it  was  more  than  her  strength  could  endure.  A  little 
over  two  years  after  the  operation  she  died  suddenly  of  heart-fail- 
ure. The  post-mortem  revealed  the  heart  lesions  which  proved 
fatal.  The  part  of  the  tumor  which  was  left  had  not  grown,  in 
fact,  it  jDrobably  had  diminished.  The  scar  at  the  point  of  the 
deepest  enucleation  showed  that  there  was  no  middle  coat  of  the 
uterus  at  the  side  of  attachment  of  the  tumor.  These  facts  proved 
conclusively  that  in  operating  I  had  gone  through  to  the  perito- 
naeum, as  I  thought  I  did  at  the  time. 

The  following  cases,  treated  by  hysterectomy,  are  from  the  work 
of  Dr.  Thomas  Keith  : 

Large  Solid  Fibroid,  Weight,  Forty-two  Pounds ;  Supra-Vaginal 
Hysterectomy;  Recovery.  (Keith).— Mary  C,  aged  twenty-eight, 
was  sent  into  the  Royal  Infirmary  by  Dr.  Robertson,  of  Ardros- 
san.  She  had  sought  relief  in  many  quarters  in  vain.  The  tumor 
was  very  large,  and  was  fii'st  noticed  five  or  six  years  before.  She 
was  wasted  about  the  chest  and  arms,  like  a  case  of  old  ovarian 
disease. 

The  abdomen  measured  forty-nine  inches  at  the  umbilicus ;  the 
tumor  was  firm  and  solid  throughout.  The  ensiform  cartilage  was 
turned  upward,  and  the  growth  extended  under  the  sternum  and 
ribs;  close  to  the  sternum  there  was  a  large  projection  the  size  of  a 
child's  head.  No  trace  of  the  ovaries  could  be  detected.  The  greater 
part  of  the  pelvis  was  occupied  by  the  tumor.  There  was  no  dis- 
tinct cervix,  only  a  small  triangular  projection  drawn  to  the  left 
side,  almost  beyond  reach  of  the  finger.  For  several  years  no  great 
inconvenience  had  resulted  ;  menstruation  was  nevQr  in  excess,  and 
for  the  last  fifteen  months  it  had  entirely  ceased ;  since  then,  the 
increase  in  the  tumor  had  been  rapid,  and  she  could  do  little  or  noth- 


FIBROMA  OF  THE  UTERUS.  395 

ing  owing  to  its  weight.  She  sat  all  day  knitting ;  at  twenty-eight, 
her  life-prospects  were  anything  but  bright. 

For  obvious  reasons,  this  j)atient  was  not  taken  down  to  the 
large  tlieati-e,  but  was  operated  on  in  the  ward,  on  the  18th  of  April, 
1881.  Sulphuric  ether  was  given,  and  the  operation  was  performed 
under  carbolic-acid  spray.  The  sponges,  thirty  in  number,  had 
been  lying  for  a  long  time  in  a  five-per-cent  solution  of  carbolic 
acid ;  they  were  washed  in  hot  water,  and  then  put  into  a  two-per- 
cent solution,  and  wrung  almost  dry.  These  were  used  over  and 
over  again,  and  were  not  washed  in  any  fresh  solution  during  the 
operation.  Dr.  Wilson  was  present  from  Glasgow,  and  there  were 
about  twenty  visitors  and  students.  The  first  incision  measured 
twelve  inches  ;  it  terminated  four  inches  above  the  pubes,  so  as  to 
avoid  the  bladder,  which  was  to  be  elevated  on  the  tumor.  On  the 
right  side,  the  broad  ligament  rose  as  high  as  the  crest  of  the  ilium. 
The  left  broad  ligament  was  largely  spread  over  the  half  of  the 
tumor  as  high  up  as  the  ribs.  The  opening  was  then  enlarged  to 
twenty-two  inches,  and,  by  dint  of  hard  pushing  and  patience,  the 
huge  mass  was  slowly  moved  forward  as  far  as  its  connection  on  the 
left  side  would  permit. 

The  right  ovary  was  easily  seen.  On  searching  for  the  left,  it 
was  found  to  be  transformed  into  a  long,  tense,  umbilical -like  cord, 
seven  or  eight  inches  in  length.  Here  and  there  along  this  tense 
band  were  several  small  cysts.  It  was  so  imbedded  in  the  tumor 
that  it  never  could  have  been  removed.  The  right,  broad  ligament 
was  transfixed  by  soft-iron  wires,  secured  and  divided  ;  all  bleeding 
from  the  tumor  was  prevented  by  a  series  of  strong-locking  forceps. 
The  fibroid  was  now  more  easily  dealt  with.  It  was  drawn  for- 
ward, so  as  to  put  on  the  stretch  its  enormous  connection  on  the 
left  side.  About  a  dozen  powerful-locking  forceps,  ten  inches  in 
length,  were  now  applied  to  the  broad  ligament  before  and  behind. 
The  whole  was  then  cut  downward,  and  the  mass  enucleated  as  low 
as  possible.  A  strong,  soft-iron  ligature  embraced  the  base,  which 
was  of  great  thickness. 

The  tumor  was  then  cut  away,  the  stump  showing  a  section  of 
the  cervix  in  the  centei.  The  forceps  were  removed  one  by  one, 
and  all  bleeding  vessels  separately  tied.  Some  of  these  were  large, 
and  one  threw  blood  over  the  assistant's  head.  There  was  much 
trouble  in  finding  some  bleeding  points  among  the  loose  cellular 
tissue  of  the  huge  gap  now  left. 

The  haemorrhage  was  mostly  venous.  All  present  could  see  that 
the  condition  was  full  of  danger,  and  that  secondary  hiwmorrhage 


396  DISEASES  OF  WOMEN. 

into  this  loose  tissue  was  not  one  of  tlie  smallest  risks  of  the  opera- 
tion. When  all  oozing  seemed  to  have  ceased,  the  stump  (the  thick- 
ness of  the  leg)  and  the  end  of  the  right,  broad  ligament  were  se- 
cured, with  much  tension,  outside;  a  glass  drainage-tube  was  iixed 
in  above  the  stump,  and  the  wound  closed  by  forty  silk  sutures. 
The  operation  lasted  one  hour  and  three  quarters.  After  much 
blood  and  serum  had  escaped  from  the  tumor,  its  weight  was  forty- 
two  pounds. 

Ten  hours  after  the  operation,  five  ounces  and  a  half  of  sirupy 
blood  were  removed  from  the  pelvis  through  the  tube.  The  pulse 
was  94 ;  the  temperature  102*2° ;  rising  two  hours  afterward  to 
103'4°.  During  the  night,  back-pain  was  relieved  by  injections  of 
morphia. 

The  first  day  was  passed  fairly  well.  In  the  evening  the  pulse 
was  126,  and  the  temperature  102'2° ;  flatulence  was  troublesome. 
She  felt  w^eak,  and  had  whisky  and  water  to  drink.  There  were 
only  four  ounces  of  bloody  serum  from  the  tube. 

On  the  third  morning,  the  pulse  was  120,  and  the  temperature 
104°. 

On  the  fourth  day,  the  pulse  was  114  to  125  ;  the  temperature 
ranged  from  101°  to  103-5°. 

On  the  fifth  day,  after  a  restless  night,  the  temperature  had  risen 
to  106°  ;  it  fell  to  104°,  and  again  in  the  afternoon  it  rose  to  105-5.° 
There  was  OBdema  of  the  labia,  and  much  cellular  infiltration  in  the 
pelvis.  She  looked  very  ill  during  these  days,  not  caring  for  food, 
though  taking  stimulants  freely  ;  on  the  sixth  day  the  pulse  dropped 
to  92,  and  the  temjDerature  also  fell  to  101-6°.  The  tube  was  re- 
moved, there  being  only  a  tablespoonful  of  reddish  serum  in  the 
pelvis.  On  the  ninth  day  the  wound  was  found  healed  throughout. 
The  stump  was  dry  and  sweet.  The  pulse  and  temperature  almost 
normal. 

In  the  tliird  week  there  was  again  a  rise  of  pulse,  and  of  tem- 
perature from  101°  to  103.°  This  continued  for  ten  days,  and 
caused  some  anxiety. 

On  the  eighteenth  day,  the  wii-es  were  loose  and  were  removed. 
The  loop  was  two  inches  and  three  quarters  in  diameter.  Seven 
weeks  after  the  operation  she  left  the  hospital.  She  is  now  a  strong 
woman,  in  ]ierfect  health,  and  can  do  anything. 

Soft  Bleeding  Fibroid;  Intra-Peritoneal  Treatment  of  Pedicle; 
Recovery.  (Keith).— In  1876,  Dr.  Kidd,  of  Alyth,  sent  me  an  un- 
married woman — a  domestic  servant — with  a  fibrous  tumor,  low  in  the 
pelvis  and  extending  to  the  umbilicus.     She  was  no  longer  able  for 


FIBROMA   OF  THE  UTERUS.  397 

her  situation,  partly  from  pain  and  partly  from  excess  at  the  menstrual 
periods.  She  was  twenty-nine  years  of  age,  and  of  fairly  healthy 
appearance.  I  advised  her  to  delay  interference,  unless  such  be- 
came absolutely  necessary.  After  three  years  she  came  again,  very 
anxious  for  relief.  She  was  much  changed ;  the  tumor  now  tilled 
the  abdomen  ;  she  was  extremely  anaemic,  and  quite  unfit  to  make 
her  living  in  any  way.  The  tumor  varied  much  in  size :  very  large 
and  tense  before  menstruation,  much  smaller  and  softer  after  this 
was  over.     The  loss  of  blood  was  sometimes  very  great. 

Operation  was  on  July  16,  1879.  Carbolic  spray  was  used. 
An  incision  not  exceeding  ten  inches  was  made ;  by  taking  time, 
the  tumor  molded  and  could  be  pushed  through  the  opening. 
Both  broad  ligaments  extended  up  to  the  fundus  of  the  tumor  on  a 
level  with  the  ribs.  The  portion  containing  the  ovarian  vessels  was 
first  transfixed  and  ligatured,  locking-forceps  being  put  on  close  to 
the  tumor,  before  the  ligament  was  divided.  The  same  process  was 
repeated  on  the  other  side.  The  tumor  was  then  separated  down- 
ward all  around  from  its  cellular  attachments,  and  a  soft-iron  wire, 
secured  quite  low  down — in  this  case,  almost  round  the  top  of  the 
vagina — by  Koeberle's  instrument.  There  was  thus  left  a  large 
cavity,  from  which  the  pelvic  portion  of  the  tumor  had  been  shelled 
out.  Koeberle's  instrument — five  and  a  half  inches  in  length — was 
left  dipping  into  the  pelvis,  as  it  could  not  be  secured  outside. 
There  was  little  bleeding  from  the  separated  surfaces,  and  the  wound 
was  kept  as  open  as  possible  around  the  instrument,  to  allow  of  the 
escape  of  serum. 

The  operation  lasted  one  hour  and  a  quarter.  There  was  a  good 
deal  of  pain,  and  several  opiates  were  required  during  the  afternoon, 
There  was  very  free  perspiration  for  some  days.  The  highest  pulse 
reached  was  124,  about  thirty  hours  after  the  operation  ;  the  highest 
temperature  was  100*5°.  Recovery  was  uninterrupted.  The  serre- 
noeud  came  away  with  the  slough  in  ten  days ;  she  returned  home 
thirty-two  days  after  the  operation,  the  wound  being  quite  cicatrized 
for  some  days. 

The  tumor  was  a  soft,  oedematous  fibroid,  and  weighed  nineteen 
pounds.    This  patient  has  enjoyed  perfect  health  since  the  operation. 

Fibrous  Tumor  of  Uterus,  containing  an  Inflamed,  Suppurating 
Cavity;  Operation;  Recovery.  (Keith). — An  unmarried  woman, 
aged  forty-four,  was  admitted  into  the  Royal  Infirmary  in  February, 
1874,  under  Dr.  Matthews  Duncan.  She  was  a  pale,  thin,  un- 
healthy looking  woman.  She  had  granular,  everted  eyelids,  and 
was  half -blind  from  inflammation  of  the  cornea.     Up  till  the  pre- 


398  DISEASES  OF  WOMEN. 

vioTis  June  her  health  was  fairly  good.  She  was  then  obh'ged  to 
give  up  her  situation  as  cook  in  London,  where  she  had  hved  for 
more  than  twenty  years. 

Menstruation  was  regular  and  normal.  Five  weeks  before  ad- 
mission a  tumor  was  detected.  It  was  hard,  elastic,  quite  fixed,  and 
reached  to  the  umbiHcus.  The  cervix  was  drawn  to  the  left  side  of 
the  pelvis ;  it  was  almost  beyond  reach  of  the  finger,  and  felt  as  if 
lost  in  the  tumor.  This  was  supposed  to  be  ovarian.  I  never  had 
any  doubt  that  the  case  was  one  of  uterine  fibroid,  and  declined  to 
operate  on  it. 

After  two  months'  residence  in  the  hospital  she  was  dismissed, 
and  went  to  her  friends  in  the  north. 

In  the  course  of  the  summer  she  began  to  write  letters  to  say 
that  she  suffered  severely,  and  that  the  tumor  had  increased.  She 
was  importunate,  and  wished  something  tried.  At  last,  wearied  by 
her  importunity,  she  was  allowed  to  come  back.  The  tumor  had 
certainly  got  much  larger ;  its  appearance  was  changed.  It  was 
very  tender  now,  and  had  become  prominent  on  the  right  side,  push- 
ing the  loin  outward.  There  was  some  free  fluid.  The  feeling  of 
elasticity  was  less  marked,  while  that  of  a  deep,  obscure  fluctuation 
was  pretty  distinct. 

The  relations  in  the  pelvis  were  the  same,  the  tumor  filling  the 
whole  upper  pelvis.  It  was  everywhere  fixed  and  immovable.  On 
September  5th,  a  needle  was  put  in  at  the  umbilicus,  and  sixty 
ounces  of  a  dark-brown  fluid  were  removed.  This  was  pronounced 
to  be  ovarian.  There  was  little  apparent  diminution  of  the  tumor. 
Much  irritation  followed  the  puncture,  and  in  ten  days  the  tension 
was  greater  than  ever.  The  aspirator  was  again  used ;  the  same 
quantity  of  fluid,  which  was  again  said  to  be  ovarian  was  removed. 
This  time  much  relief  followed.  She  was  again  sent  away,  for  I 
had  not  changed  my  mind,  and  still  thought  the  tumor  was  uterine. 
She  was  encouraged  to  hope  that,  as  menstruation  seemed  about  to 
cease,  the  tumor  would  quiet  down. 

In  a  few  weeks  she  was  back  again,  urgent  for  operation  at  any 
risk ;  her  life  was  miserable  from  pain,  her  health  had  given  way, 
and  she  had  to  work  that  she  might  live.  The  case  was  now  quite 
a  clear  one  for  interference,  and  I  willingly  agreed  to  try  and  remove 
the  tumor,  the  patient  clearly  understanding  that  this  might  not  be 
accomplished. 

On  December  12th  an  incision,  twelve  or  fifteen  inches  was  made 
at  once.  The  tumor  was  of  a  dusky-brown  color,  covered  by  enor- 
mous veins.     It  was  firmly  attached  to  the  right  iliac  fossa,  right 


FIBROMA  OF  THE   UTERUS.  399 

lumbar  region,  and  to  tlie  wall  from  a  little  below  the  umbilicus. 
This  extent  of  adhesion  quite  accounted  for  the  iixed  state  which  the 
tumor  liad  always  presented.  Upward  of  four  pints  of  a  dirty, 
black,  purulent-looking  fluid  were  removed,  the  incision  was  en- 
larged, and  with  one  strong  pull  of  the  arm,  pushed  in  from  behind, 
the  adhesions  were  broken  up  and  the  tumor  dragged  out.  So  rap- 
idly was  blood  lost  from  huge,  torn  veins  in  the  capsule,  that  she 
became  faint.  The  left  ovary  only  could  be  included  in  the  wire 
ligature.  From  the  previous  elevation  of  the  cervix,  the  stump  was 
secured  in  the  lower  angle  of  the  wound  with  less  tension  than  in 
the  iirst  case.  This  part  of  the  operation  occupied  only  a  few  min- 
utes, but  it  was  upward  of  two  hours  ere  the  wound  was  closed. 
Much  trouble  arose  from  stopping  bleeding  in  the  torn  adhesions, 
more  especially  those  high  up  on  the  insides  of  the  ribs,  near  the 
posterior  margin  of  the  liver.  A  glass  drainage-tube  was  left  in, 
passing  to  the  bottom  of  the  pelvis.  The  patient  was  pulseless  when 
placed  in  bed.  This  was  an  anxious  operation  on  account  of  the 
unusual  loss  of  blood. 

It  is  unnecessary  to  give  details  of  the  slow  convalescence.  The 
tube  was  removed  on  the  fourth  day,  and  the  whole  amount  of  red 
serum  that  came  away  did  not  exceed  three  ounces.  This  could 
easily  have  been  absorbed.  The  pulse  had  fallen  to  below  100  by 
the  fifth  day^  and  there  was  scarcely  any  disturbance  of  the  tem- 
perature. There  was,  however,  much  flatulence  during  the  second 
and  third  weeks,  also  much  trouble  with  the  bowels,  and  at  one  time 
there  was  a  fear  of  obstructed  intestine.  It  was  thought — though 
there  was  no  evidence  of  this — that  there  might  have  been  some 
adhesion  at  the  angles  of  the  bowel,  caused  by  the  presence  of  the 
drainage-tube.  As  in  the  former  case,  the  slough  extended  far  be- 
yond the  wire,  and  a  large  cavity  was  left  on  its  separation. 

Six  weeks  later  she  went  home.  I  saw  her  quite  recently.  She 
was  in  perfect  health,  and  had  been  so  ever  since  her  operation,  now 
nearly  ten  years  ago. 

The  application  of  electrolysis  to  the  treatment  of  fibroids  has 
been  so  thoroughly  elaborated  by  Prof.  George  J.  Engelmann,  M.  D., 
of  St.  Louis,  that  I  have  with  his  permission  given  here  a  few  cases 
from  his  work  on  that  subject : 

Uterine  Fibro-myoma  with  Menorrhagia,  Retro-uterine  Hematocele, 
and  Left  Cellulitis. — The  hgemorrhagic  state  of  this  case,  the  existing 
inflammation,  which  was  active,  subacute,  contra-indicated  electrol- 
ysis or  negative  electro-puncture.  To  check  the  haemorrhage,  posi- 
tive electro-cauterization  was  resorted  to,  the  platinum  sound  con- 


400  DISEASES  OP  WOMEN. 

nected  with  the  anode  in  the  uterus,  the  large  dispersing  cathode 
upon  the  abdomen.  At  the  first  sitting  a  current  of  60  milliamp^res 
was  used  for  eight  minutes,  no  stronger  current  being  admissible  on 
account  of  the  existing  inflammation.  The  effect  was  good,  hem- 
orrhage and  pain  lessened.  Two  days  later  the  treatment  was  re- 
peated, 100  milliaraperes  used  for  six  minutes;  bleeding,, which  Lad 
been  almost  constant,  was  stopped.  After  three  further  treatments 
upon  alternate  days,  the  menses  appeared  :  previously  profuse,  now^ 
normal  in  quantity.  This  symptom  being  overcome,  the  inflamma- 
tory conditions  were  attacked  by  vagino-abdominal  galvanism ;  the 
negative  pole,  a  large  metallic  ball  covered  with  absorbent  cotton, 
moistened  in  warm  water  applied  per  vagina,  the  large  plate  in  con- 
nection with  the  positive  pole  upon  the  abdominal  surface  of  the 
exudation.  From  40  to  60  milliamperes  were  so  used,  serving  to 
relieve  the  pain.  Hsemorrhage  and  excessive  suffering  being 
overcome,  the  patient  was  ordered  to  bed  at  her  home,  and  di- 
rected to  continue  the  use  of  poultices  and  hot-water  injections 
until  more  active  measures  could  be  taken  for  the  destruction  of  the 
tumor. 

Uterine  Fibro-myoma  (bilobar)  extending  to  one  finger's  breadth 
above  the  navel. 

First  tentative  treatment.  May  2d  :  negative  electro-puncture ; 
small  stylet  introduced  to  the  depth  of  3  centimetres;  80  milliamperes 
for  five  minutes. 

Second  puncture,  May  5th :  large  platinum  stylet  introduced  to 
the  depth  of  4  centimetres  ;  an  intensity  of  100  milliamperes  for  five 
minutes ;  no  pain  was  experienced  from  the  internal  electrode,  and 
the  abdominal  burning  diminished  greatly  toward  the  end  of  the 
sitting. 

Third  sitting,  after  an  easy  menstrual  period.  May  12th  :  80  mil- 
liamperes, six  minutes ;  highest  portion  of  the  tumor  3^  centimetres 
below  the  navel. 

Fourth  sitting,  May  24th :  60  milliamperes,  eight  minutes ;  large 
stylet  introduced  to  the  depth  of  7  centimetres ;  highest  portion  5 
centimetres  below  navel. 

May  31st,  notwithstanding  that  a  current  of  only  60  milliamperes 
had  been  applied  on  account  of  insufficiency  of  the  battery,  local  pain 
followed,  the  tumor  enlarged  in  circumference,  extending  above  the 
navel,  became  tense,  swollen,  apparently  fluctuating  ;  no  rise  of  pulse 
or  temperature.     Treatment  deferred. 

June  2d,  fifth  treatment :  50  milliamperes,  six  minutes ;  tumor 
harder,  less  elastic,  much  diminished. 


FIBROMA   OF  TPIE   UTERUS.  401 

June  Yth,  sixth  treatment :  large  stylet,  8  centimetres,  60  milH- 
amperes,  seven  minutes. 

June  15th,  seventh  treatment :  60  milliamperes,  ten  minutes ; 
tumor  very  hard,  extending  half-way  to  umbilicus ;  pelvis,  which 
had  at  first  been  almost  full,  more  free ;  vagina,  which  had  been  a 
fan-like  expansion,  now  assuming  more  normal  proportions.  Ice-bag 
immediately  after  treatment,  since  it  had  answered  well  when  applied 
during  the  apparently  inflammatory  enlargement.  The  patient  re- 
turned to  her  home  after  the  ninth  treatment  greatly  improved  in 
health,  functions  re-established,  the  tumor  reduced  very  much  in 
size.     Each  of  the  nine  sittings  had  lasted  from  five  to  ten  minutes. 

Uterine  Fibro-myoxna. — General  debility,  scanty  menstruation. 
Patient  aged  thirty-two.  A  fibro-myoraa,  similar  to  the  last,  filling 
the  pelvic  cavity,  its  left  half  extending  to  the  height  of  the  navel, 
the  right  an  inch  and  a  half  lower,  the  uterine  cavity  possessing  a 
depth  of  13  centimetres.  This  tumor,  which  had  been  first  noticed 
in  Kovember,  1885,  had  been  rapidly  growing,  notwithstanding 
active  local  and  constitutional  treatment,  mainly  with  ergot,  at  the 
hands  of  one  of  our  ablest  gynecologists,  first  came  under  my  ob- 
servation March  9, 1886,  recommended  to  me  by  her  previous  attend- 
ant, my  esteemed  friend  Prof.  Boishniere. 

April  28th,  first  tentative  treatment ;  the  puncture  made  with  a 
small  stylet ;  a  current  of  45  milliamperes  was  used  for  five  minutes. 
Treatment  was  continued  once  a  week,  the  puncture  hereafter  being 
made  with  a  large  platinum  stylet  through  the  cervical  tissue,  and 
the  prominent  vaginal  projections  of  both  right  and  left  masses, 
which  were  punctured  to  a  depth  of  from  7  to  8  centimetres.  For 
the  six  treatments  following  the  first,  a  current  of  from  100  to  110 
milliamperes  was  used ;  then  a  still  higher  intensity,  from  160  to 
200,  was  applied.  The  burning,  occasionally  intense,  often  decreased 
to  a  minimum  toward  the  end  of  the  sitting  (by  reason  of  the  anaes- 
thetic effect  of  the  positive  pole),  the  punk-  and  chamois-covered 
plate  being  used,  leaving  the  abdomen,  after  its  removal,  sometimes 
slightly  reddened,  but  always  cool.  This  patient,  feeble,  subject  to 
fevers,  at  first  did  not  improve  constitutionally.  The  tumor,  after 
the  third  puncture,  was  3  centimetres  below  the  navel  on  the  left 
side,  4  on  the  right — the  pelvis  more  free,  a  most  decided  shrinkage, 
due,  I  presume,  in  part  to  the  powerful  contraction  caused  by  the 
high  intensity  used.  In  this  case  free  bleeding  followed  several  of 
the  applications,  from  one  to  six  hours  after  treatment,  after  the 
fourth  puncture ;  coming  at  one  time  when  still  on  the  table,  checked 
with  considerable  difliculty  by  iron  cotton  tampons.     By  June  2Sth 

27 


402  DISEASES  OP   WOMEN. 

the  tumor  seemed  again  to  increase ;  her  general  condition  not  hav- 
ing improved,  menstruation  still  being  excessively  scant,  a  mere 
show,  I  endeavored  to  further  constitutional  improvement,  using  no 
internal  remedies,  as  she  complained  of  her  stomach,  which  had 
been  ruined  by  constant  but  ineffective  medication  ;  electrolysis  was 
stopped,  and  negative  electro-cauterization  resorted  to  for  the  pur- 
pose of  increasing  the  flow.  The  uterine  cavity  then  measured  11 
centimetres. 

July  1st,  negative  electro-cauterization  ;  100  milliamperes,  six 
minutes.  July  12th,  100  milliamperes,  eight  minutes.  July  16th, 
150  milliamperes,  ten  minutes,  no  discomfort  whatsoever  being  ex- 
perienced from  the  intra-uterine  negative  pole. 

August  6th,  menses  free,  continuing  five  days ;  more  profuse  and 
better  than  ever  before  since  first  established ;  she  has  gained  three 
and  a  half  pounds  in  the  last  month  ;  looks  much  better ;  feels  well. 
This  treatment  was  continued,  with  interruptions,  during  the  sum- 
mer ;  menses  more  free  than  they  had  been  for  years ;  her  general 
condition  much  improved.  No  medication  whatsoever  was  re- 
sorted to. 


CHAPTER    XXII. 

MALIGNANT   DISEASE    OF   THE    UTEEUS. 

A  VERY  important,  and  a  very  frequent  class  of  diseases  is  that  in- 
cluded in  the  above  term  ;  and  for  this,  if  for  no  other  reason,  must 
we  have  a  clear  notion  of  the  terminology  so  often  misapphed. 

Malignant  growths  are  those  which  tend  to  infiltrate  and  destroy 
adjacent  tissue,  to  recur  after  removal,  possibly  originate  remote 
secondary  neoplastic  formations,  and  which  cause  steady  deteriora- 
tion of  the  general  health  without  regard  to  location.  They  are 
not  necessarily  "  cancers." 

Cancer  is  an  "  atypical  epithehal  neoplasm,"  distinct  from 
growths  of  the  pure  connective-tissue  type.  Its  forms  are  few  and 
pretty  well  settled  and  agreed  upon.  The  first  is  scirrhus,  hard, 
chronic,  or  fibrous  cancer ;  the  second  is  soft,  acute,  medullary,  or 
encephaloid  cancer ;  the  third  is  colloid,  "  gum,"  or  alveolar  cancer ; 
but  whether  epithelioma  is  a  fourth  variety  or  is  itseK  a  distinct 
form  is  still  a  mooted  question. 

Epithelioma  is  often  intensely  malignant ;  and  the  term  "  can- 
croid "  is  a  safe  one  as  it  certainly  is  like  a  cancer. 

Another  vexed  question  is  whether  cancer  of  the  uterus  is  a  local 
exhibition  of  a  constitutional  malady,  or  is  at  first  local  and  only 
later  infects  the  system  generally. 

The  same  uterus  may  be  the  seat  of  several  varieties  of  carci- 
noma ;  or,  again,  the  neoplasm  may  change  from  one  form  into 
another  as  well  without,  as  after,  surgical  interference. 

Sarcomata  are  malignant  directly  in  proportion  to  the  lo^vness  of 
their  organization.     They  are  of  the  embryonal-tissue  type. 

CANCER  OF  THE  CERVIX. 

The  body  of  the  uterus  is  so  seldom  the  seat  of  carcinosis  that 
when  the  unqualified  phrase  "  cancer  of  the  uterus "   is  used,  it 

403 


404  DISEASES  OF  WOMEN. 

means  of  the  cervix.  Malignant  disease  of  the  corpus  will  be  con- 
sidered separately. 

Excepting  epithelioma,  scirrhus  is  the  most  frequent  variety, 
says  one  class  of  gynecologists ;  encephaloid,  says  the  other.  They 
are  both  right,  for  I  believe  the  initial  stage  to  be  nearly  always  the 
hard  carcinoma,  which  subsequently  becomes  soft  and  medullary  ; 
and  since  it  is  only  the  later  form  that  is  apt  to  produce  symptoms 
sufficiently  marked  for  the  patient  to  consult  a  physician,  this  may 
account  for  the  supposed  rarity  of  scirrhus,  as  compared  with  en- 
cephaloid cancer  of  the  uterus. 

With  this  idea  of  the  development  of  the  neoplasm  in  view  the 
pathology  will  l?e  given. 

Pathology. — One  lip  of  the  cervix  becomes  hard,  uneven,  and 
h}^3ertrophied,  and  the  nodules,  which  (probably)  originate  in  the 
submucous  tissue,  subsequently  ulcerate  through  the  mucous  mem- 
brane, which  is  now  covered  with  vascular  vegetations,  especially 
near  the  orifice  ;  the  opposite  lip  suffers  an  identical  lesion,  the  cer- 
vical orifice  enlarges  and  now  the  whole  cervix  is  covered  with  veg- 
etations. 

The  cellular  tissue  of  the  vaginal  mucosa  just  beneath  this  fun- 
goid mass  which  projects  into  the  vagina,  becomes,  in  its  turn,  in- 
durated, uneven,  and  granulated,  while,  simultaneously,  the  muscu- 
lar coat  of  the  cervix  is  being  infiltrated  with  the  growth. 

The  mucous  ulceration  is  frequently  gangrenous,  and  a  fetid 
fluid,  containing  shreds  of  dead  connective  tissue  and  portions  of 
vessels  wliich  supplied  the  necrosed  part,  bathes  the  surface  at  the 
cervico- vaginal  junction  where  the  loss  of  continuity  is  best  marked ; 
and  thus  a  hob-nailed  or  fungating  mass  entirely  takes  the  place  of 
what  we  should  normally  feel  upon  a  vaginal  examination.  In  very 
rare  cases  the  carcinomatous  mass  is  removed  in  toto  as  a  gangrenous 
slough,  and  then  the  ulcerated  patch  that  remains  is  walled  in  by 
normal  tissue.     It  is  to  all  ajjpearance,  a  phagedenic  ulcer. 

Microscopically,  a  section  of  scirrhus  shows  small  cavities  (alve- 
oli) surrounded  by  thick  fibrous  stroma,  and  in  the  alveoli  are  only 
a  few  polyhedral  cells. 

An  encephaloid  section  exhibits  a  delicate  and  scanty  frame- 
work surrounding  large  alveoli  which  are  crowded  with  cells  (many 
of  which  are  fatty)  in  a  milk-white  fluid,  the  "  cancer-juice."  The 
section  from  such  a  tumor  is  light  in  color  and  mottled.  In  the  ves- 
sels are  plugs  made  up  of  cancer-cells  and  fibrin ;  the  walls  of  these 
vessels  are  pigmented  and  isittj. 

Either  variety  is  melanotic,   when  the  blood   pigment   in  the 


MALIGNANT  DISEASE   OF   THE   UTERUS.  405 

stroma  and  alveoli  is  so  ricli  as  to  produce  a  deep  brown  or  black 
hue. 

Finally,  one  of  the  rarest  forms  of  carcinoma  uteri  is  colloid  can- 
cer ;  the  dilference  between  it  and  encephaloid  (of  which  it  is  a 
modification)  is  that  the  cells  enlarge  and  are  filled  with  colloid  ma- 
terial, the  alveoli  enlarge  also,  and  as  the  stroma  thins,  one  cavity 
communicates  with  another  so  that  anfractuous  spaces  are  formed 
filled  with  a  transparent  gum- like  substance. 

The  pathological  effects  of  cancer  of  the  womb  are  many  and 
important.  It  may  extend  to,  and  perforate  through  the  vesical 
wall ;  this  occurs  of tener  than  one  out  of  three  cases,  and  cystitis  al- 
ways precedes  the  rupture. 

Yesico-vaginal  fistulse  are  by  no  means  uncommon,  and  here  we 
shall  often  find  severe  gangrenous  processes  attending. 

Rectitis  may  be  excited  and  the  wall  of  the  rectum  be  perfo- 
rated. These  are  not  half  so  frequent  as  bladder  lesions.  When, 
however,  both  structures  are  opened  there  is  a  cloacal  intercommu- 
nication of  vagina,  rectum,  and  bladder. 

When  stenosis  of  the  ureters  results  either  from  external  press- 
ure or  from  thickening  of  their  walls,  we  will  find  the  kidney  anse- 
mic  and  full  of  urine  (hydronephrosis). 

The  cellular  tissue  of  the  broad  ligament  and  iliac  fossae  is  infil- 
trated, and,  later,  undergoes  purulent  infiltration,  frequently  induc- 
ing peritonitis,  while  the  vessels  and  lymphatics  leading  to  such 
purulent  collections  are  the  seat  of  carcinomatous  inflammation. 

The  peritonaeum  of  Douglas's  cul-de-sac  is  jDushed  upward  and 
pseudo-membranes  inclose  the  uterus  both  anteriorly  and  poste- 
riorly. 

The  subperitoneal  connective  tissue  of  the  true  pelvis  is  thick, 
bard,  and  adherent  to  the  bones  ;  it  may  press  on,  and  cause  fatty 
changes  in  the  sciatic  and  pelvic  nerves. 

The  body  of  the  uterus  may  be  infiltrated,  the  organ  being  as 
large  as  when  pregnant.  Its  walls  may  measure  one  and  one  half 
inch  in  thickness. 

The  tubes  are  rarely  involved ;  and  if  carcinoma  be  located  at 
first  solely  in  the  cervix  the  ovaries  always  escape. 

When  cancer  proHferates  downward  in  the  vaginal  walls  it  forms 
numerous  nodes,  as  far  as  the  introitus  vaginae,  so  that  a  physical 
examination  will  become  diflicult  or  impossible. 


406  DISEASES  OF  WOMEN. 


EPITHELIOMA  OF  THE   CERVIX. 

Cancroid,  formerly  called  rodent  ulcer  of  the  cervix,  is  not  so 
malignant  as  scirrhus  or  encephaloid  carcinoma.  It  seems  to  be  of 
a  more  local  character  than  the  other  neoplasms  of  this  group. 

It  appears  in  one  of  two  forms — as  pavement-celled  epithelioma 
or  as  cylindrical-celled  epithelioma.  Excepting  colloid  cancer,  this 
last  is  the  rarest  form  of  uterine  neoplasm. 

Pathology. — Pavement-celled  epithelioma  begins  in  the  epithelia 
of  the  vaginal  portion  of  the  cervix,  the  tumor  formed  being  waxy, 
slightly  vascular  in  spots,  and  dry  on  its  surface.  Tlie  mass  is  fria- 
ble ("  fragile  cancer "),  and  on  pressure  we  can  squeeze  out  white 
worm-like  plugs,  composed  of  epitlielial  cells. 

I  have  occasionally  found  this  variety  to  begin  within  the  cervical 
canal,  and  extend  outward  (not  downward),  so  that  on  exploration 
the  mass  could  be  scooped  out,  leaving  the  cervix  a  mere  shell,  its 
exterior  or  vaginal  portion  showing  few  if  any  signs  of  new  growth. 

The  tumor  is  lobulated,  and,  when  the  lobules  compress  the  ves- 
sels, gangrene  results,  and  all  that  part  of  the  cervix  that  is  carcinom- 
atous may  drop  off,  or  a  deep,  crater-like  ulcer  is  excavated  whose 
edges  are  always  nodular ;  hence  the  term  "  ulcerating  epithelioma." 

Squamous  epithelioma  extends  to  the  body  and  fundus,  but  in 
general  its  spread  is  limited  by  the  nearest  chain  of  lymphatics. 

Microscopically,  a  tubular  structure  is  often  seen,  the  tubes  being 
surrounded  by  a  fibrous  material,  and  probably  originating  from  the 
culs-de  sac  of  the  cervical  glands. 

The  appearance  of  the  section  has  given  the  name  "  cystic  epi- 
thelioma "  to  it.  When  the  tumors  are  crowded  with  lobulated  nests 
of  cells,  connected  together  with  epithelial  bands,  the  centers  are 
filled  either  with  colloid  matter  or  a  hard  mass  resembling  ordinary 
callous  (such  as  that  on  the  hand  or  foot). 

Cylinder-celled  epithelioma  originates  as  a  pedunculated  or  ses- 
sile  vascular  wart ;  and,  although  the  dendritic  tumor  begins  in  a 
single  spot,  it  tends  toward  the  vagina  in  its  growth,  and  spreads 
downward  as  the  so-called  "  cauhflower  excrescence,"  often  as  large 
as  a  hen's  q^q,,  and  not  rarely  completely  filling  the  vagina. 

The  glands  are  so  distended  that  the  French  pathologists  call  this 
"  adeno-carcinoma." 

At  first  the  cylinder  cells  of  the  cervical  mucosa  form  a  soft  mass, 
with  a  milky  juice ;  thus  it  is  hard  to  differentiate  it  from  enceph- 
aloid except  by  the  aid  of  the  microscope. 

Non-maliguant  papillomata  also  resemble  these  vegetating  epi 


MALIGNANT  DISEASE   OF  THE  UTERUS.  407 

theliomata,  and,  without  a  microscropical  examination,  whether  a 
cauliflower  excrescence  is  or  is  not  malignant  can  not  be  determined. 
With  such  an  examination  the  non-malignant  is  seen  to  lie  upon 
healthy  submucous  tissue,  the  mahgnant  upon  unhealthy ;  the  non- 
malignant  is  a  simple  anastomosing  framework,  while  the  mahgnant 
growth  has  an  alveolar  arrangement  with  cell-nests. 

This  form  of  cancroid  invariably  ulcerates ;  and,  though  occur- 
ring late  in  the  disease,  this  process  is  rapid  and  destructive,  large 
vessels  often  being  eroded. 

Microscopically,  it  consists  of  numerous  long  stems,  all  intercon- 
nected, each  stem  having  at  its  center  a  vascular  loop,  the  exterior 
covering  being  long  cylinder  cells  ;  thus  it  is  Hke  an  intestinal  villus, 
only  longer,  and  the  numerous  vessels  among  the  masses  of  cells  jjer- 
mit  serum  to  ooze  through  their  walls,  and  this  is  the  chief  source 
of  the  watery  discharge  of  this  disease. 

The  points  of  secondary  invasion  are  many ;  the  bones,  lungs, 
liver,  bladder,  rectum,  pelvic  nerves,  adjacent  lymphatics,  and  the 
uterus  have  been  the  loci  of  later  malignant  growth,  and  in  the 
uterus  it  occupies  the  fibro-muscular  structure  as  numerous  and  par- 
tially distinct  nodules. 

Symptomatology. — Malignant  disease  of  the  womb  runs  no  typi- 
cal course.  As  with  cancer  elsewhere,  so  here  there  is  a  stage  where 
a  tumor  is  forming,  and  a  stage  where  it  ulcerates. 

During  the  first  of  these  stages  the  amount  of  pain,  the  leucor- 
rhoea,  and  haemorrhage  are  so  slight  that  few  patients  will  consult 
the  physician  about  them.  And,  as  I  have  said,  it  is  probably  for 
this  reason  that  scirrhus  is  considered  a  rare  form  of  cancer.  And 
let  me  say  at  the  very  outset  that  the  lancinating  pain  so  often  men- 
tioned all  through  our  literature  as  strongly  symptomatic  of  carci- 
noma uteri  is  exceptionally  met  with  in  this  disease. 

A  discharge  is  the  earliest  symptom  in  the  majority  of  cases. 
This  discharge  may  be  bloody,  watery,  or  leucorrheal.  As  a  rule 
it  assumes  the  character  of  an  intense  menorrhagia,  the  patient  also 
bleeding  between  the  menstrual  epochs  either  sjDontaneously  or  from 
sudden  exercise  or  coition.  Some  women  will  state  that  although 
their  change  of  life  occurred  a  year  or  so  ago,  that  now  they  have 
"  commenced  again." 

The  bloody  discharge  may  or  may  not  be  fetid  and  grumous,  but 
the  organic  matter  which  forms  the  grumous  discharge,  and  which 
is  continually  sloughing  away  and  passing  out  of  the  genitals,  very 
seldom  causes  any  septicaemia.  Besides,  the  lymphatics  are  not  here 
abundant  in  the  immediate  neighborhood  of  the  cancerous  tumor. 


408  DISEASES  OF  WOMEN. 

Watery  discharges  consist  chiefly  of  the  clear  serum  of  the  blood ; 
they  are  usually  odorless  at  first,  but  soon  become  mingled  with 
ulcerative  debris,  and  are  peculiarly  foul  smelling.  They  are  seldom 
or  never  free  from  admixture  of  blood,  and  there  are  very  few  who 
will  not  give  "  bloody  water  "  as  one  of  their  chief  symptoms. 

The  watery  flux  is  almost  characteristic  of  the  cauliflower  excres- 
cence. 

In  many  cases  the  discharge  is  simply  leacorrheal  up  to  the  time 
of  ulceration  of  the  cancer,  after  which  the  fetid  "  cancer  smell " 
and  molecular  masses  from  the  growth  indicate  the  true  cause  of  the 
discharge. 

A  sudden  bright  haemorrhage  indicates  that  a  medium-sized  ar- 
tery has  been  opened. 

The  more  rapidly  the  neoplasm  forms,  and  the  more  extensively 
it  ulcerates,  the  more  profuse  and  fetid  will  be  the  discharge. 

Excoriations,  erosions,  erythema,  vaginitis,  vaginismus,  intense 
pruritus,  and  similar  conditions  may  result  from  the  passage  of  these 
discharges  through  and  over  the  genitals. 

Pain  is  never  so  prominent  a  symptom  as  the  discharge,  and, 
according  to  some,  never  a  symptom  so  long  as  the  cervix  alone  is 
the. seat  of  malignant  growth.  The  character  of  the  pain  is  described 
differently  by  different  patients,  as  dull,  boring,  gnawing,  shooting, 
and  stabbing. 

The  pain  shoots  in  the  direction  of  the  parts  supplied  by  branches 
of  the  nerve  whose  main  trunk  is  pressed  upon.  The  back,  pelvis, 
and  thighs  are  the  chief  regions  of  this  kind  of  pain. 

The  pain  is  more  acute  when  the  terminal  nervous  branches  are 
involved  than  when  the  trunk  alone  is  compressed ;  and  it  is,  again, 
more  severe  when  there  is  a  large  amount  of  neoplastic  tissue  formed 
than  when  ulceration  is  extensive. 

The  pain  of  peritonitis,  which  may  be  lighted  up  by  the  growth, 
has  characters  peculiar  to  itself 

The  amount  of  tenderness  is  not  always  in  proportion  to  the 
pain. 

Pain  on  motion  and  from  coition  (dyspareunia)  is  experienced 
almost  from  the  onset  in  neoplasms  of  the  cervix ;  later  on,  defeca- 
tion and  urination  may  produce  intolerable  suffering.  Pain  as  a 
symptom  may  be  absent  throughout  the  disease,  and  the  patient  only 
experience  weight  and  bearing  down. 

As  the  disease  progresses,  the  patient  first  loses  strength,  appe- 
tite, and  all  cheerfulness  of  disposition,  emaciation  following  later 
on.    The  face  assumes  an  earthy  green,  or,  toward  the  end,  a  bronzed 


MALIGNANT  DISEASE   OF  THE  UTERUS. 


409 


hue,  and  the  temperature  may  be  slightly  subnormal.    There  is  som- 
nolence and  headache,  but  eclampsia  is  infrequent. 

The  bowels  are  constipated,  as  a  rule,  but  irritation  or  actual 
cancer  of  the  rectum  may  cause  profuse  and  exhaustive  diarrhoea ; 
haemorrhoids  are  common.  Cystitis,  strangury,  and  retention  or  in- 
continence are  not  infrequent  bladder  symptoms. 

When  fistulas  form,  they  give  rise  to  their  usual  symptoms.  In 
one  case  the  first,  and,  indeed,  the  symptom  on  which  the  diagnosis 
was  made,  was  a  flow  of  urine  from  the  region  of  the  cervix. 

The  breasts  are  frequently  the  seat  of  sympathetic  pain.    Toward 

the  close  of  the  disease  there 
is  usually  a  slight  febrile  move- 
ment in  contrast  with  the  tem- 
perature in  the  early  stages  of 
the  disease. 

Physical  Signs. — Scirrhus 
carcinoma  gives  a  hard,  hob- 
nailed or  nodular  feel  to  the 
finger  during  the  earliest  sta- 
ges, and  the  mucosa  seems  to 
be  immovably  fixed  on  the  sub- 
jacent connective  tissue,  a  con- 
dition not  met  with  except  in 
malignant  growths. 

When  any  cancer  has  ul- 
cerated (the  usual  time  when 
the  physician  sees  it),  the  fin- 
ger meets  a  friable,  irregular  mass,  which  bleeds  upon  the  slightest 
provocation,  and  which  is  surrounded  by  a  tough,  unyielding,  irreg- 
ular zone  of  infiltrated  tissue.  If  reached,  the  lips  of  the  cervix  are 
felt  to  be  uneven,  thick,  and  spreading  downward  like  a  mushroom. 
Palpation  may  further  reveal  in  many  cases  fistulas,  immobility 
of  the  womb,  changes  in  the  size  and  position,  and  infiltrations  and 
indurations  in  the  neighborhood. 

In  scirrhus  the  womb  is  felt  to  be  low  down  in  the  pelvis. 
The  bowels  may  have  been  so  constipated  that  the  physician 
examines  for  stricture  of  the  rectum  before  searching  for  anything 
else ;  but  in  doing  this  he  will  directly  suspect  the  true  state  of 
affairs,  and  especially  so  if  the  pelvic  cellular  tissue  or  neighboring 
glands  be  involved. 

A  second  physical  sign,  which  is  supposed  by  some  to  be  diag- 
nostic, is  that  a  sponge  tent  or  uterine  dilator  fails  to  dilate  a  cervix 


Fig.  188. — Cancer  of  both  lips  (Winckel). 


410  DISEASES  OF   WOMEN. 

suffering  from  malignant  disease,  whereas  in  all  other  neoplasms  dila- 
tion will  qnickly  and  easily  follow  its  introduction, 

A  third  physical  sign  is  indescribable ;  it  is  the  odor  that  the 
finger  has  after  such  an  examination — an  odor  produced  by  nothing 
else  but  cancer, 

A  fourth  means  of  physical  diagnosis  is  the  speculum,  by  the 
use  of  which  we  see  what  has  already  been  described  under  the  head 
of  pathology.  Commencing  scirrhus  is  accompanied  by  a  deep  pur- 
plish or  livid  hue  of  the  entire  cervix,  and  enlarged  vessels  are  seen 
to  ramify  about  these  nodules. 

The  extent  of  the  growth  can  only  be  accurately  appreciated  by 
this  means  of  examination.  Epithelioma  of  the  cervical  cavity  is 
often  diagnosticated  solely  by  the  use  of  the  speculum  and  curette 
or  probe. 

Lastly,  the  microscope  may  be  used  not  only  to  diagnosticate  the 
presence  or  absence  of  carcinoma,  but  to  decide  which  variety  we 
have  to  deal  with.  It  should  be  stated  here  that  malignancy  can 
not  be  decided  by  the  microscope,  since  it  is  a  clinical  property. 

The  microscopical  ajDpearances  of  each  form  have  already  been 
described. 

Diagnosis. — Before  treating  of  the  points  in  which  cancer  and 
other  lesions  of  the  uterus  differ,  it  is  necessary  to  mention  the  char- 
acters that  especially  distinguish  one  form  of  carcinoma  from  an- 
other. 

Scirrhus  gives  a  nodular,  hard  sensation  on  palpation,  immobility 
of  mucosa  upon  sub-mucosa,  prevents  cervical  dilatation  on  using 
the  sponge  tent  or  the  uterine  dilator,  showing  less  of  elasticity  in 
the  tissues,  and  the  discharge  is  scanty. 

In  medullary  cancer  the  grumous  discharge  containing  molecu- 
lar debris  is  the  prominent  symptom.  The  course  of  this  cancer  is 
the  most  acute  of  all.  The  brittle,  crumbling,  ulcerated  mass  is  pe- 
culiar to  this  form.     The  uterus  is  usually  fixed  and  immovable. 

Epithelioma  is  accompanied  by  a  more  profuse  watery  discharge 
than  any  other  variety ;  and  on  palpation  the  finger  meets,  often, 
the  characteristic  cauliflower-like  mass.  The  uterus  even  late  in  the 
disease  suffers  no  fixation,  and  may  be  moved  without  pain.  This 
variety  seems  more  local  than  the  preceding. 

In  all  instances  when  cancer  is  diagnosticated  a  microscopical  ex- 
amination will  determine  what  variety  we  are  dealing  with  ;  and  to 
this  end  a  piece  of  the  tumor  may  be  removed  by  the  curette. 

There  are  numberless  conditions  with  which  cancer  in  general 
may  be  confounded  ;  the  chief  of  these  are  : 


MALIGNANT  DISEASE  OP   THE  UTERUS.  411 

Sloughing'  Myomata  or  Fibrous  Polypi. — These  may,  either  of  them, 
simulate  cancer  ;  but  they  will  be  attended  by  fever,  which  is  absent 
in  cancer,  and  there  will  be  in  the  discharges  shreds  of  the  normal 
uterine  tissue,  while  in  cancer  discharges  epithelial  cells  will  be 
prominent.  Frequent  washings  control  the  former,  while  cancer 
remains  unmodified  thereby. 

Syphilitic  Ulceration. — This  not  only  resembles  cancer,  but  may 
even  produce  vesico-recto-vaginal  fistulse.  Here  the  history,  the 
age  of  the  patient,  the  effects  of  local  and  constitutional  treatment, 
the  discharge,  and  an  examination  of  a  small  bit  of  the  tumor  will 
soon  allow  a  diagnosis  to  be  reached. 

Condylomata. — These  will  not  long  be  mistaken  for  cancer. 

Erosions. — These  are  numerous ;  but  non-malignant  erosions  oc- 
cur in  younger  patients,  produce  no  constitutional  symptoms,  leave 
no  portion  of  the  cervix  intact,  are  attended  with  large,  gaping  fis- 
sures, and,  on  inspection  by  means  of  the  speculum,  large  ovula  N^a- 
bothi  are  seen.  The  discharge  does  not  have  the  cancerous  odor  in 
benign  erosions. 

The  points  in  connection  with  cancer  of  the  body  and  cancer  of 
the  cervix  are  considered  hereafter. 

Prognosis. — It  is  needless  to  say  that  the  invariable  tendency  of 
malignant  uterine  disease  is  toward  death.  The  chief  question  in 
prognosis,  therefore,  is  of  the  duration  of  life.  There  are  no  hard 
and  fast  rules  for  the  expectation  of  life,  nor  do  my  own  statistics 
or  those  of  others  afford  definite  statements. 

Three  months  and  three  years  are  the  extreme  figures  given. 

In  general,  it  may  be  stated  that,  a-fter  the  first  marked  symptom 
(some  discharge),  the  patients  live  a  year,  except  those  who  have 
epithelioma  or  cancroid  ;  these,  as  a  rule,  have  eighteen  months  of 
life  before  them. 

A  prognosis  should  never  be  made  immediately  after  diagnosti- 
cating cancer ;  the  physician  should  wait  until  the  disease  pronounces 
itself  a  slow  or  rapid,  an  uncomplicated  or  a  complicated,  a  localized 
or  an  extending  process. 

Among  the  complications  are  hydronephrosis  (see  pathology), 
and,  consequently,  ursemia,  cellulitis,  and  peritonitis,  and,  less  fre- 
quently, septicaemia,  phlebitis  with  venous  thrombosis,  embolism, 
and  cancer  in  adjacent  tissues  and  distant  organs,  the  liver  especially. 

Death  may  result  from  simple  exhaustion  (cancerous  marasmus), 
or  from  haemorrhage  when  a  large  vessel  is  opened,  or  from  rup- 
ture of  the  uterus  (rare),  or  from  any  of  the  above-named  complica- 
tions. 


412  DISEASES   OF   WOMEN. 

Death  is  sometimes  dela^^ed  and  torturing,  and,  in  the  face  of  its 
being  inevitable,  it  often  seems  as  though  it  were  a  mercy  to  hasten  it. 

Etiology. — Until  puberty  the  death-rate  from  cancer  is  the  same 
in  both  sexes  ;  from  this  period  both  frequency  and  death-rate  stead- 
ily increase  in  the  female  up  to  and  a  little  after  the  menopause,  at 
which  period  the  difference  in  rate  between  the  sexes  is  most  marked. 
After  the  age  of  fifty  there  is  a  tendency  for  cancer  to  appear 
equally  often  in  both  sexes. 

There  is  no  doubt  but  that  there  is  such  a  condition  as  a  predispo- 
sition to  malignant  disease ;  but  to  what  extent  this  can  be  inherited 
or  not  is  not  yet  determined.  It  is  well  known,  however,  that  cer- 
tain peculiarities  of  organization  predispose  to  malignant  disease. 
Among  these  is  the  cardio-vascular  hypoplasia  (Virchow),  where  the 
pulmonary  arteries  are  undersized,  and  which  occurs  often  with  the 
phlegmatic  temperament,  characterized  by  an  abundant  adipose  tis- 
sue and  an  appearance  of  health,  which  is  an  appearance  and  noth- 
ing else. 

Great  differences  are  met  with  in  authorities  as  to  the  frequency 
of  cancer ;  reliable  statistics,  however,  tell  us  that  the  uterus  was  at- 
tacked in  three  thousand  cases  out  of  a  total  of  sixty-one  thousand 
seven  hundred  and  fifteen  cases  of  carcinoma  (anywhere  in  the 
body)  in  females.  The  same  also  afford  us  proof  that  the  uterus  is 
cancerous  three  times  as  often  as  any  other  female  organ. 

Heredity  has  an  undoubted  influence ;  I  have  gathered  the  sta- 
tistics of  many  thousand  cases,  and  find  that  an  inherited  taint  can 
be  traced  in  thirteen  per  cent  of  all  cases  on  an  average. 

Age  is  the  most  potent  factor  in  the  etiology.  Before  puberty, 
indeed  before  the  age  of  twenty,  cancer  is  unknown  or  phenomenal. 
I  have  seen  two  cases — both  ending  fatally — where  the  patients 
were  in  their  twenty-seventh  and  twenty-eighth  year  respectively ; 
and  the  sister  of  the  last  named  died  of  cancer  of  the  uterus  in  her 
thirty-first  year. 

The  ten  years  following  the  menopause  (forty  to  fifty)  is  the 
period  of  carcinoma  uteri  ;  the  decade  following  this  is  the  next 
most  eventful  period,  and  third  in  order  stand  the  ten  years  preced- 
ing the  climacteric. 

Race  seems  to  have  little  or  no  influence.  Perhaps  it  is  pecul- 
iar to  my  practice,  yet  I  have  seen  more  cases  of  carcinoma  uteri 
among  Germans  than  in  any  other  nationality. 

There  is  more  than  an  accidental  agreement  between  cancer  and 
the  number  of  children  born  ;  for  it  will  be  found  that  patients  with 
cancer   of  the   uterus  will   average   one   third   more   children  than 


MALIGNANT  DISEASE   OF  THE   UTERUS.  413 

women  free  from  malignant  disease  of  the  womb  ;  indeed,  every 
case  of  carcinoma  uteri  will  average  five  children,  a  large  family 
at  the  present  time. 

Prolonged  lactation,  anti-hygienic  surroundings,  poor  or  improper 
food,  exhausting  diseases,  grief,  and  anxiety  are  all  more  apt  to  be 
accompanied  by  cancer  than  an  opposite  condition  of  affairs ;  never- 
theless, seventy-five  per  cent  of  cases  will  give  a  history  of  good 
health  up  to  the  development  of  this  neoplasm. 

It  is  quite  certain  that  laceration  or  erosion  of  the  cervix  has  a 
causative  influence  upon  cancroid  ;  hence  in  suspected  epithelioma 
the  previous  history  must  always  be  elicited.  I  do  not  mean  that 
laceration  will  cause  it ;  but  with  a  latent  tendency,  an  erosion  or 
laceration  will  often  determine  the  precise  point  of  eruption  of  the 
disease. 

In  recent  times  pathologists  have  favored  the  idea  that  cancer  is 
dependent  upon  a  certain  germ.  When  this  comes  to  be  better  un- 
derstood, it  is  possible  that  medical  treatment  may  be  suflicient  to 
prevent  or  to  cure  this  affection.  But  at  the  present  time  our  knowl- 
edge of  the  disease  appears  to  be  limited  to  the  fact  that  certain  or- 
ganizations are  predisposed  to  cancer  disease ;  and  if  it  should  be 
found  in  the  future  that  the  disease  is  due  to  a  cancer  germ,  the  fact 
will  still  remain  that,  in  order  that  this  germ  may  be  effective  in 
producing  cancer,  a  certain  kind  of  organization  or  a  certain  quality 
of  tissue  is  favorable  to  the  action  of  this  germ.  It  is  known  that 
the  tubercle  bacilli  (and  the  germ  of  cancer,  if  there  is  one),  require 
a  certain  kind  of  tissue  to  live  upon,  hence  some  enjoy  an  immunity 
from  these  maladies,  while  others  are  predisposed  to  them. 

Some  of  the  diseases  due  to  specific  germs  attack  all  alike,  the 
strong  and  the  weak — typhoid  fever,  for  example.  It  is  very  differ- 
ent with  such  diseases  as  cancer.  Those  germs  that  require  special 
tissue  to  live  upon  act  locally.  The  other  germs  that  attack  all  or- 
ganizations are  general  in  their  action. 

There  are  certain  things  that  we  know  now  which  obtain  almost 
invariably  in  cases  that  develop  cancer — such,  for  example,  as  the 
fact,  pointed  out  long  ago  by  Virchow,  that  the  pulmonary  artery  is 
abnormally  small  in  those  who  die  of  cancer.  I  have  kept  a  record 
of  a  very  large  number  of  cases  of  cancer  of  the  uterus,  mammary 
glands,  and  ovaries,  and  I  think  I  can  say  that,  without  exception,  I 
have  found  the  pulmonary  circulation  defective,  and  consequently 
respiration  and  blood  aeration  insufficient  to  a  certain  degree. 

The  vast  majority  of  subjects,  also,  have  been  stout,  with  a  pre- 
ponderance of  adipose  and  cellular  tissue.     In  fact,  they  have  been 


414  DISEASES  OP   WOMEN. 

somewhat  chlorotic  as  a  rule,  and  of  the  lymphatic  temperament. 
In  short,  while  digestion  and  assimilation  have  been  normal,  disas- 
similation,  disintegration,  and  elimination  have  been  imperfect  or 
sluggish.  It  would  seem,  therefore,  that  this  condition  of  organiza- 
tion predisposes  to  malignant  disease ;  and  if  such  is  the  fact,  then 
much  can  be  done  in  the  way  of  development  and  general  manage- 
ment in  early  life  to  overcome  this  peculiar  tendency  to  disease. 
All  that  was  said  in  discussing  the  management  of  chlorotic  and 
phlegmatic  girls  would  apply  with  equal  force  to  the  prevention  of 
cancer.  I  need  not,  then,  in  this  connection,  dwell  upon  that  part 
of  the  subject. 

The  condition  of  the  organization  at,  toward,  or  immediately 
after  the  menopause  especially  favors  the  appearance  of  cancer. 

The  diagnosis  of  this  condition  is  based  upon  the  special  tem- 
perament, usually  phlegmatic,  somewhat  chlorotic,  it  may  be,  with 
small  circulatory  apparatus,  at  any  rate  so  far  as  the  pulmonary 
artery  is  concerned,  and  hence  the  imperfect  respiration  and  blood 
aeration  referred  to,  the  superabundance  of  adipose  and  cellular 
tissue,  as  shown  by  the  general  appearance  of  the  patient,  with  slug- 
gish excretion  or  elimination,  indicated  chiefly  by  renal  and  hepatic 
torpor.  These  conditions  of  ultimate  nutrition  are  very  often 
spoken  of  as  lithaemia,  and  hence  I  might  say  that  lithsemic  patients 
at  this  period  of  life  are  predisposed  to  cancer. 

It  will  be  seen  that  this  condition  may  be  largely  due  to  in- 
herited temperament  and  general  organization,  and  yet  to  a  large 
extent  it  may  be  acquired.  Some  of  the  modifications  of  nutrition 
which  have  been  referred  to  in  discussing  the  menopause  clearly 
eventuate  in  this  predisposition  to  malignant  disease. 

Dr.  Arthur  W.  Johnston  (in  whose  opinion  I  have  profound 
confidence)  believes  that  the  chief  cause  of  carcinoma  is  failure  of 
the  trophic  nerves,  the  failure  being  brought  about  by  some  nerve 
strain  or  great  sorrow.  I  accept  without  hesitation  the  theory  re- 
garding the  causative  relation  of  the  trophic  nerves  to  cancer,  but 
my  clinical  experience  makes  me  doubt  if  nerve  strain  is  the  primary 
cause.  I  incline  to  the  opinion  that  failure  of  the  trophic  nerves 
occurs  more  readily  in  those  organizations  which  I  have  described  as 
j)redisposed  to  malignant  disease.  But  whether  the  nerve  strain  is 
a  necessary  element  in  the  causation  of  cancer  or  not,  the  trophic 
nerves,  which  preside  over  all  tissue  changes,  certainly  play  an  im- 
portant part  in  the  ni3tiology  of  cancer,  and  have  a  certain  bearing 
on  the  question  of  treatment. 

Treatment. — This  may  be  divided  into  the  medical  and  surgical. 


MALIGNANT  DISEASE  OP  THE  UTERUS.  415 

The  first  indications  in  this  condition  are  to  improve  the  character 
of  the  tissues,  first  by  diet,  and  then  by  every  possible  means  which 
can  favor  ultimate  nutrition  by  promoting  the  depleting  processes, 
or  disintegration  and  elimination. 

In  regard  to  the  matter  of  diet,  I  am  confident  that  all  the 
articles  of  food  and  drink  which  retard  tissue  waste  or  elimination 
of  worn-out  tissues,  such  as  alcohol  (es}>ecially  in  the  form  of  beer), 
tea,  and  cofliee,  should  be  avoided.  Certain  observations  that  I  have 
made  lead  to  the  conclusion  that  beer-drinking  people,  and  to  a  less 
extent  Mane-drinkers,  are  more  subject  to  cancer.  This  is  an 
additional  reason  for  my  urging  the  restricted  use  of  such  articles 
through  life,  and  especially  at  the  time  when  cancer  is  likely  to 
appear.  The  excessive  use  of  animal  food,  while  it  may  not  in 
itself  predispose  to  malignant  disease, 'does  so  when  it  is  used  in  ex- 
cess in  connection  with  alcohol ;  and  those  who  take  sparingly  of 
animal  food,  I  find,  can  bear  a  larger  amount  of  alcohol  with  less 
injurious  effects.  And  so,  in  given  cases,  if  I  found  that  they  took 
animal  food  sparingly,  but  alcohol  in  considerable  quantity,  I  should 
continue  the  alcohol  but  diminish  the  quantity.  It  is,  I  presume, 
on  account  of  this  effect  of  animal  food  and  alcohol  in  producing  a 
tendency  to  cancer  that  milk  diet  has  obtained  a  considerable  repu- 
tation in  the  management  of  malignant  disease. 

Kext  to  diet,  every  means  should  be  employed  to  regulate  the 
renewal  of  tissue  ;  and,  first,  by  getting  clear  of  waste  material. 
Diet  having  been  properly  adjusted,  and  food  given  in  quantities 
that  can  be  easily  and  thoroughly  digested,  will  insure  the  best  pos- 
sible supply  of  tissue.  Then  if,  by  the  means  at  command,  free 
disintegration  and  elimination  can  be  secured,  much  will  be  accom- 
plished toward  preventing  the  appearance  of  cancer.  The  bowels 
should  be  kept  regular,  and  yet  not  unnecessarily  free.  The  kid- 
neys should  be  made  to  do  their  whole  duty,  and  the  intestinal 
secretions,  including  hepatic  secretion,  should  be  carefully  looked 
after.  The  skin  also  requires  attention  ;  and  here  I  believe  the 
Turkish  bath  is  of  value,  especially  to  those  who  have  not  sufficient 
exercise  to  induce  free,  healthful  perspiration.  A  Turkish  bath 
once  or  twice  a  week,  with  thorough  massage,  will  greatly  improve 
the  ultimate  nutrition.  Exercise  should  be  carefully  regulated.  It 
is  a  rare  thing  to  see  cancer  in  an  active  person  who  does  not  carry 
a  superabundance  of  adipose  tissue,  and  who  takes  a  suflicient 
amount  of  muscular  exercise,  and  yet  not  too  much.  If  diet,  exer- 
cise, and  eliminating  agents  be  employed  to  excess,  so  that  the  re- 
newal of  tissue  is  insufiicient,  and  the  patient  becomes  debilitated 


416  DISEASES  OF   WOMEN. 

and  suffers  from  lack  of  nutritive  supply,  the  tendency  to  malignant 
disease  will  be  favored. 

Care  must  always  be  taken  not  to  overdo  the  eliminating  pro- 
cess. The  balance  between  waste  and  repair  should  be  maintained 
as  nearly  perfect  as  possible,  the  great  object  being  to  secure  com- 
plete ultimate  nutrition,  so  that  the  tissues  may  not  become  too 
old  and  worn  out  before  they  are  broken  down  and  thrown  off.  I 
am  not  sure  that  I  will  be  thoroughly  understood  when  I  speak  of 
old  tissues,  but  I  apply  the  term  to  a  condition  in  which  the  process 
of  w^aste  and  repair  is  retarded,  and  the  tissues  are  not  broken  down 
and  thrown  off  after  they  have  served  their  purpose.  That  is  what 
I  mean,  and  that  is  the  condition  which  I  believe  favors  the  appear- 
ance of  cancer,  and  the  chief  thing  to  be  overcome  by  treatment 
directed  to  prevent  it.  Dr.  Johnston's  views  regarding  causation 
suggest  the  necessity  for  the  use  of  agents  that  may  improve  the 
condition  of  the  nervous  system.  This,  of  course,  is  largely  accom- 
plished through  improvement  of  the  general  nutrition,  but  nerve 
tonics,  and  sedatives  if  needed,  should  be  employed. 

This  leads  up  to  the  consideration  of  medicinal  agents  which  are 
supposed  to  have  some  influence  on  the  ultimate  nutrition,  and  which 
have  been  used  in  the  past,  in  the  hope  of  preventing  cancer  or  of 
arresting  its  progress  when  it  has  manifested  itself  in  any  location. 

A  number  of  remedies  have  been  employed  in  the  past,  and  we 
may  say  of  most  of  them  that  they  have  been  weighed  in  the  bal- 
ance and  found  wanting.  At  one  time  condurango,  Chian  turpen- 
tine, and  several  others,  were  lauded  for  their  curative  power  in  can- 
cer, but  they  have  been  found,  if  not  useless,  almost  so.  Those 
that  are  used  most  at  the  present  day,  and  which  still  claim  some 
confidence,  are  prepared  chalk  and  arsenic. 

In  regard  to  the  chalk,  which  was  first  used  in  the  form  of 
calcined  oyster  shells,  given  in  powders,  ten  to  twenty  grains,  three 
times  a  day,  there  were  several  theories  regarding  its  action,  but 
whether  they  were  correct  or  not  is  unknown.  From  personal  ex- 
perience I  am  unable  to  say  that  this  agent  is  reliable.  As  it  is  a 
harmless  article,  I  can  see  no  objection  to  using  it ;  but  I  would 
rely  far  more  upon  arsenic.  Arsenic  has  a  decided  influence  upon 
ultimate  nutrition,  especially  of  the  skin  and  mucous  membranes ; 
and  as  cancer  usually  makes  its  appearance  in  those  tissues,  anything 
that  can  improve  their  nutrition  must  be  of  some  benefit.  Such  is 
the  fact,  based  upon  the  therajKnitic  action  of  arsenic,  and  the  same 
thing  is  observed  clinically.  On  this  account  I  have  employed  this 
remedy  in  the  management  of  the  conditions  which  I  believe  pre- 


MALIGNANT   DISEASE   OF   THE    UTERUS.  417 

dispose  to  cancer  and  in  cases  wliere  cancer  actually  had  appeared, 
and"  with  benefit.  On  the  same  principle  I  have  employed  mercury 
and  iodine,  a  favorite  prescription  being  small  doses  of  chloride  of 
mercury  with  arsenic,  continued  for  a  time  and  then  changed  for 
iodine  and  arsenic.  Small  doses  of  the  latter,  and  also  of  the  mer- 
cury, should  be  employed,  as  it  is  a  long-continued  action  which 
gives  the  result. 

These  are  the  remedies  that  at  the  present  time  are  most  effica- 
cious, and  I  believe  that  if  persistently  continued,  and  if  begun 
early  in  the  course  of  the  disease,  but  more  especially  if  employed 
when  there  is  an  apparent  tendency  to  the  disease,  they  are  poten- 
tial preventives — at  any  rate,  the  best  there  are.  When  cancer  is 
present,  I  need  hardly  say  that  surgical  treatment  is  indicated,  and 
is  the  only  treatment  that  promises  any  relief. 

Within  the  past  few  years  much  has  been  said  with  reference  to 
the  effect  of  pyoctanin,  an  aniline  preparation.  This,  I  am  satisfied, 
is  of  some  value  in  arresting  the  progress  of  the  disease  when  ap- 
plied locally,  but  this  belongs  to  the  domain  of  surgery.  What 
effect  it  may  have  when  given  internally  is  not  decided. 

A  word  may  be  said  regarding  the  treatment  of  cancer  by  local 
applications  in  the  way  of  plasters  and  caustics,  and  so  on.  This, 
of  course,  is  surgical  treatment,  and  the  most  barbarous  kind  of  sur- 
gery, and  so  nothing  further  need  be  said  on  that  subject. 

It  sometimes  happens  that,  after  the  surgeon  has  done  his  best 
for  the  relief  of  malignant  disease,  his  ejEforts  fail,  and  the  patient 
falls  into  the  hands  of  the  physician  in  her  last  days.  There  is  only 
one  word  to  say  on  that  subject.  Under  these  circumstances  the 
physician's  first  and  only  duty  is  to  give  relief  and  add  to  the  com- 
fort of  the  patient  as  far  as  possible.  Opium  is  the  agent  which 
alone  can  do  this,  and  I  believe  in  the  free  use  of  it  in  the  manage- 
ment of  such  cases — doses  sufficient  to  relieve  pain.  I  may  add  that 
I  believe  that  not  only  does  opium  relieve  pain  in  cancer,  but  it  re- 
tards the  progress  of  the  disease.  I  have  an  idea  that  the  habitual 
use  of  opium  prevents  cancer  to  a  limited  extent. 

All  that  has  been  said  in  this  connection  applies  equally  to  can- 
cer of  the  uterus,  ovaries,  or  mammary  glands,  which  covers  the 
whole  field  of  the  gyntecologist. 

Surgical  Treatment. — Complete  removal  of  all  the  diseased  tis- 
sues is  the  classical  treatment  of  cancer  of  the  cervix  uteri.  In  the 
past  this  was  accomplished  in  several  ways — by  caustics,  amputation 
with  the  knife,  ablation  with  the  curette  and  thermo-cautery,  and  in 
recent  years  with  the  galvano-cautery  by  Byrne's  method. 
28 


418  DISEASES  OF  WOMEN. 

Since  vaginal  liysterectomy  lias  been  perfected,  tlie  vast  majority 
of  surgeons  prefer  to  remove  the  entire  uterus  when  cancer  is  found 
in  any  part  of  the  cervix  or  body. 

Having  had  ample  opportunities  for  observing  the  safet}^  and 
superior  results,  immediate  and  ultimate,  of  Dr.  Byrne's  operation 
for  cancer  of  the  cervix  uteri,  I  believe  that  it  is  preferable  and 
should  be  adopted.  Many  surgeons  who  adopted  Byrne's  method 
complained  of  having  trouble  with  the  battery,  owing  to  their  not 
knowing  how  to  keep  it  in  order.  There  is  nothing  reasonable  or 
valid  in  such  objection,  and  now  that  the  electric-light  power  is  in 
most  of  the  hospitals  and  houses  and  can  be  utilized  for  running 
the  cautery  instruments  such  objections  can  no  loTiger  be  raised.  The 
cautery  instruments  devised  and  used  by  Dr.  Byrne  are  to  be  found 
at  the  instrument  makers,  and  therefore  I  need  not  describe  them 
here.     The  method  I  prefer  giving  in  the  doctor's  own  words: 

High  Amputation  of  the  Cervix  Uteri  in  Cancer. — "  In  conditions 
admitting  of  high  amputation,  the  following  is  the  method  usually 
resorted  to :  The  uterus  is  to  be  exposed  and  the  vaginal  walls  pro- 
tected in  the  manner  already  described.  The  diverging  volsellnm 
being  passed  well  into  the  cervical  canal,  should  now  be  expanded 
to  a  proper  degree  and  locked,  so  as  to  afford  complete  control  of 
the  uterus  during  the  entire  operation. 

"  By  alternate  traction  and  upward  pi-essure  of  the  uterus  an 
accurate  idea  may  now  be  obtained  as  to  the  proper  point  to  begin 
the  circular  incision,  so  as  to  avoid  injuring  the  bladder  or  opening 
into  the  cul-de-sac  of  Douglas.  As  to  the  latter,  however,  should 
it  be  found  that  the  disease  has  involved  the  retro-uterine  tissues, 
and  that  its  excision  or  destruction  by  the  cautery  can  not  be  effected 
without  opening  into  the  peritoneal  cavity,  there  need  be  no  hesita- 
tion in  doing  so,  as  I  have  never  known  any  harm  to  come  from  it 
whether  done  accidentally  or  by  design.  Should  it  be  evident  at 
tlie  outset  that  the  operation,  in  order  to  be  thorough,  must  include 
a  portion  of  the  cul-de-sac^  it  will  be  better  to  make  the  line  of  in- 
cision anterior  to  this,  until  the  cervix  has  been  removed,  and  leave 
the  excision  of  the  retrouterine  parts  by  the  cautery  knife  to  be  the 
final  proceeding.  Under  these  circumstances  all  that  will  be  lUH'ded 
will  l)e  an  antiseptic  tampon  ]iro])erly  apjilied. 

"  In  proceeding  to  make  the  circular  incision,  the  cautery  knife 
slightly  curved  and  cold,  should  be  applied  close  up  to  the  vaginal 
junction,  and  from  the  moment  that  the  current  is  turned  on  should 
ha  kept  in  contact  with  the  parts  being  incised.  Before  removing 
the  electrode  for  any  purpose,  such  as  change  of  position  or  alter- 


MALIGNANT   DISEASE   OP   THE   UTERUS.  41 9 

ing  the  curve  of  the  knife,  the  current  should  be  stopped,  and  the 
instrument  again  placed  in  position  while  cool  before  resuming  in- 
cision. In  other  words,  if  the  knife,  though  heated  only  to  a  dull 
red,  be  applied  to  parts  at  all  vascular,  hiemorrhage  more  or  less 
will  certainly  follow  ;  whereas,  the  cool  platinum  blade  being  already 
in  contact  with  moisture  as  the  current  is  being  transformed  into 
heat,  vessels  are  shrunken  or  closed  even  before  they  are  severed. 

"  This  is  a  very  important  point,  and  should  never  be  lost  sight 
of  in  all  cautery  operations. 

"  The  circular  incision  having  been  made  to  the  depth  say  of  a 
quarter  of  an  inch,  it  will  now  be  observed  that  by  increased  trac- 
tion the  uterus  may  be  drawn  much  farther  downward,  and  by  direct- 
ing the  knife  upward  and  inward  the  amputation  may  be  cai'ried  to 
any  desired  extent.  In  cases  calling  for  amputation  above  the  os 
internum,  it  will  be  better  to  excise  and  remove  the  cervix  first, 
then,  by  dilating  the  upper  canal  sufficient  to  admit  the  diverging 
volsellum,  once  more  proceed  as  in  the  first  instance,  taking  care, 
however,  to  keep  within  bounds.  It  will  be  found  that  the  cupped 
stump  can  now  be  drawn  down  and  made  to  project  as  a  more  or 
less  convex  body. 

"  In  all  cases  the  dome-shaped  electrode  should  be  passed  over 
the  entire  cavity  repeatedly,  so  as  to  render  the  cauterization  still 
more  complete. 

"  It  is  important  to  add  that,  in  carrying  the  knife  toward  the 
sides  of  the  cervix,  circular  and  other  arterial  branches  are  apt  to  be 
encountered,  and  hence,  in  this  locality  particularly,  a  high  degree 
of  heat  in  the  platinum  blade  is  to  be  carefully  avoided.  As  an  ad- 
ditional security  against  haemorrhage,  the  convexity  of  the  knife 
should  be  pressed  against  the  external  surface  of  each  particular 
section  cut,  so  as  to  close  vessels  more  effectually. 

"  It  is  well  to  state  that  the  metallic  parts  of  the  electrode  for 
the  distance  of  about  two  inches  should  be  covered  with  a  strip  of 
thin  flannel,  so  that  the  vagina  may  be  protected  from  injury  through 
the  reflected  heat." 

Unfortunately,  however,  cases  occur  for  whom  the  operation  just 
described  is  inapplicable,  and  yet  for  whom  something  may  be  done. 
For  such  I  know  no  better  treatment  than  that  advised  by  Dr. 
Byrne.     In  describing  this,  he  says  : 

"  It  is  well  known  to  all  who  have  had  much  experience  with 
uterine  cancer  that  in  a  very  large  percentage  of  the  cases  met  with, 
whether  in  private  or  hospital  practice,  the  disease  is  found  to  have 
already  progressed  so  far  that  palliative  results  or  a  brief  respite 


420  DISEASES   OF   WOMEN. 

from  suffering  and  death  is  all  that  can  be  hoped  for  from  any  treat- 
ment. In  such  cases,  as,  for  example,  when  the  entire  cervix  has 
been  destroyed  and  the  corpus  uteri  as  well  as  the  parametric  tissues 
are  found  to  be  involved,  my  course  has  been  as  follows  :  First,  to 
remove  all  softened  and  broken-down  tissue  by  the  free  use  of  a 
sharp  curette,  and  having  sponged  the  cavity  repeatedly  with  a 
mixture  of  one  part  of  commercial  acetic  acid,  three  parts  of  glycerin, 
and  carbolic  acid  sufficient  to  represent  eight  per  cent  of  the  whole, 
I  then  pack  the  cavity  with  absorbent  cotton  and  allow  it  to  remain 
for  a  few  minutes  or  longer  as  the  case  may  be.  On  removing 
this,  if  all  bleeding  is  found  to  have  ceased,  and  the  cavity  fairly 
dry,  cauterization  may  be  proceeded  with.  If,  however,  oozing  of 
blood  to  any  extent  sliould  still  continue,  it  will  be  best  to  pass  into 
the  cavity  a  ]>roperly  rolled  tampon  saturated  with  the  above  styptic 
and  allowed  to  remain  for  forty-eight  hours  before  the  application 
of  the  cautery. 

"  Cauterization  in  all  such  cases  should  be  conducted  in  the  fol- 
lowing manner  : 

'•  The  diseased  organ  should  be  exposed  to  view,  and  the  vagina 
protected  by  a  Sims's  speculum  and  an  anterior  and  two  lateral  re- 
tractors, and  it  may  be  necessary  to  seize  the  edges  of  the  excavation 
by  one  or  more  volsella.  Before  introducing  the  cautery  electrode 
a  wad  of  absorbent  cotton  is  to  be  passed  into  the  cavity,  held  for 
a  moment,  and,  immediately  on  being  withdrawn,  the  dome-shaped 
instrument,  brought  to  a  cherry-red  heat,  is  to  be  rapidly  and  re- 
peatedly passed  over  the  bottom  of  the  cavity  mainly.  The  latter 
is  then  to  be  again  dried  by  wads  of  absorbent  cotton  held  in  dress- 
ing forceps,  and  cauterization  resumed  as  in  the  first  instance.  This 
process  is  to  be  repeated  over  and  over  again  until  the  deeper  parts 
of  the  cavity  have  become  dry  and  charred,  when  the  sides  are  to 
be  treated  in  precisely  the  same  manner  and  roasted  to  the  same 
crisp  condition.  The  seat  of  operation  will  now  present  the  appear- 
ance of  a  perfectly  black  and  dry  cavity.  All  i-agged  aiid  over- 
lapping edges  are  next  to  be  trimmed  off  by  the  cautery  knife ;  a 
firmly  rolled  tampon  of  suitable  size  with  thread  attached,  and  satu- 
rated with  the  above  styptic  compound,  is  now  to  be  placed  in  the 
cavity,  and,  finally,  a  supporting  vaginal  tampon  is  to  be  applied 
and  the  patient  removed  to  bed.  The  vaginal  tampon  may  be 
removed  on  the  following  day,  but  the  other  should  be  allowed 
to  remain  for  forty-eight  hours  or  longer.  The  subsequent  treat- 
ment will  consist  of  vaginal  douches  twice  daily  of  carbolized 
water." 


MALIGNANT   DISEASE   OF   THE    UTERUS.  421 

CANCER   OF   THE    BODY   OF   THE   UTERUS. 

This  condition  is  rare  as  compared  witli  carcinoma  of  the 
cervix. 

Pathology. — In  corporeal  epithelioma  the  epithelium  of  the 
uterine  glands  undergoes  hypertrophy,  and  there  is  formed  a  fun- 
gating  polypoidal  mass,  which  propagates  itself  over  all  the  organ,  or 
projects  into  its  cavity,  perhaps  into  the  cavity  of  the  cervix. 

The  cancerous  mass  always  ulcerates  and  leaves  wide  cavities  in 
the  hardened  uterine  wall.     The  uterus  becomes  enlarged. 

Scirrhus  or  encephaloid  may,  in  rare  cases,  be  found  in  the  body 
of  the  womb,  although  the  best  authorities  state  that  there  is  scarcely 
an  unquestionable  case  of  corporeal  encephaloid,  and  that  scirrhus 
has  never  been  met  with. 

These  varieties  form  beneath  the  mucosa  in  the  substance  of  the 
uterine  tissue,  and  extend  outward,  causing  peritonitis  and  agglutina- 
tion with  neighboring  organs  and  parts.  When  they  extend  inward 
they  are  certain  to  ulcerate. 

Either  form  of  cancer,  when  accompanying  fibroids,  does  not 
seem  to  modify  the  latter's  characteristics.  One  case  is  recorded  of 
cauliflower  excrescence  of  the  fundus ;  this  projected  out  through 
the  cervix  down  into  the  vagina. 

The  microscopical  appearances  in  no  wise  differ  from  similar 
neoplasms  in  the  cervix. 

Symptom  otology. — The  prominent  symptoms  of  cancer  of  the 
cervix  are  also  met  with  in  cancer  of  the  body,  but  not  to  the  same 
degree  nor  appearing  in  the  same  order. 

In  cancer  of  the  body  pain  occurs  early,  and  is  severe  and  parox- 
ysmal, sometimes  remaining  at  its  pitch  for  two  hours.  Free  menor- 
rhagia  is  soon  accompanied  by  a  discharge  which  is  profuse,  watery, 
and  fetid.  In  some  instances  there  will  be  no  discharge  whatever 
throughout  the  disease.  The  vital  forces  are  early  greatly  depre- 
ciated, and  marked  constitutional  disturbance  is  a  prominent  early 
symptom  of  cancer  of  the  corpus. 

Physical  Signs. — Inspection  gives  negative  results.  On  palpa- 
tion (bimanual)  the  body  is  felt  to  be  larger  and  harder  than  normal. 
The  cervix  is  usually  dilated,  but  in  a  few  instances  has  been  felt  to 
be  normal.  Adhesions  may  firmly  hold  the  uterus  in  a  fixed  posi- 
tion, but  in  most  cases  it  is  freely  movable. 

The  probe  induces  profuse  htemorrhage  in  nearly  all  cases,  and 
by  its  use  we  learn  the  degree  of  dilatation  of  the  cavity  of  the 
womb. 


422  DISEASES  OF   WOMEN. 

The  curette  is  used  to  withdraw  some  of  the  growth  for  micro- 
scopical examination. 

Diagnosis. — Cancer  of  tlie  body  and  cancer  of  the  cervix  may 
be  confounded  with  each  other.  The  points  that  enable  us  to  dis- 
tinguish them  are  these :  Cancer  of  the  body  is  very  rare ;  that  of 
the  cervix  comparatively  common  ; .  })ain  is  very  early  and  very 
severe  in  cancer  of  the  body  ;  it  is  rare  or  absent  in  cervical  cancer. 
Menstruation  is  deranged  from  the  very  onset  in  cancer  of  the  body  ; 
this  is  a  late  symptom  when  the  cervix  is  attacked. 

Marked  constitutional  disturbance  and  peritonitis — which  is  often 
fatal — occur  early  and  more  frequently  in  cases  where  the  body  is 
the  seat  of  malignant  growth  than  when  the  cervix  is  involved. 
There  is  little  or  no  tenesmus  on  bimanual  examination  in  cancer 
of  the  cervix,  while  this  is  marked  in  cancer  of  the  body.  The 
probe  discovers  an  enlarged  corpus  in  the  latter  case,  while  in  cancer 
of  the  cervix  the  corpus  is  normal  in  size.  The  adjoining  structures 
are  implicated  far  more  frequently,  and  also  earlier  in  the  disease, 
in  cancer  of  the  body  than  in  cancer  of  the  cervix. 

Prognosis. — The  same  rules  hold  good  here  as  in  cancer  of  the 
cervix.  The  outlook  for  recovery  is  far  less  favorable,  not  only 
from  the  situation  of  the  growth  and  the  greater  likelihood  of 
adjacent  tissues  being  involved,  but  also  from  the  fact  that,  as  total 
extirpation  is  the  sole  means  of  treatment,  the  probability  of  life 
after  this  operation  is  much  less  than  after  amputation,  cautery,  or 
scooping. 

Causation. — The  body  of  the  uterus  is  attacked  with  cancer  very 
much  more  frequently  in  nulliparae  than  in  multiparse,  which  is  in 
striking  contrast  with  the  prevalence  of  cancer  of  the  cervix.  The 
average  age  of  patients  suffering  corporeal  carcinoma  is  ten  years 
greater  than  that  of  women  afflicted  with  cancer  of  the  cervix.  In 
every  other  respect  the  causation  is  the  same  as  in  cervical  cancer. 

Treatment. — Extirpation  is  the  sole  means  of  effecting  a  cure  in 
cancer  of  the  body,  and  hysterectomy  seems  to  be  followed  by  far 
better  results  in  these  cases  than  when  performed  for  cancer  of  the 
cervix.  This  may  be  accounted  for  on  the  ground  that  in  the  neigh- 
borhood of  the  cervix  there  is  far  greater  liability  to  extension  of 
the  disease  and  infiltration  downward  and  laterally. 

Vaginal  Hysterectomy. — While  the  principles  of  this  operation 
are  the  same,  the  details  differ  with  different  surgeons.  Some — the 
French  surgeons  chiefiy — control  the  uterine  and  ovarian  arteries 
with  clamps ;  others  use  ligatures. 

I  shall  descrii)e  the  operation,  and  note  the  most  important  dif- 


MALIGNANT   DISEASE   OP  THE    UTERUS. 


423 


ferences  in  the  iiietliods  of  carrying  out  the  various  steps  of  the 
procedure. 

Prejxiration  of  the  Parts  for  Operation. — The  patient  being 
placed  in  the  Hthotomy  position,  the  vulva  and  vagina  are  thor- 
oughly cleansed  and  disinfected  and  the  rectum  and  bladder  com- 
pletely emptied.  If  the  body  of  the  uterus  is  alone  affected,  the 
cervical  canal  must  be  washed  out,  packed  loosely  with  cotton,  and 
closed  with  a  pair  of  forceps  or  with  sutures.  If  the  disease  involves 
the  cervix,  so  that  the  cancerous  mass  protrudes  into  the  vagina,  as 
much  as  possible  should  be  removed  with  the  cautery  or  curette,  and 
then  the  canal  closed  in  the  manner  described.  The  object  of  this 
closure  of  the  canal  is  to  keep  the  wound  clean  and  free  from  infec- 
tion during  removal  of  the  uterus,  and  is  very  important.  It  is  im- 
portant in  such  cases  to  remove  all  the  diseased  tissue  about  and 
within  the  cervix  before  proceeding  further  in  the  operation. 

Retractors  should  be  introduced  into  the  vagina,  so  as  to  thor- 
oughly expose  the  cervix  and  upper  part  of  the  vagina.  The  cervix 
should  then  be  seized  with  a  volsellum  forceps  and  drawn  outward 
and  upward,  and  the  posterior  vaginal  wall  be  incised,  the  incision 
being  semicircular  and  extending  half  around  the  cervix  and  out- 
ward half  an  inch  or  less,  according  to  the  size  of  the  cervix.  The 
peritonseum  should  be  opened  from  the  base  of  one  broad  ligament 
to  the  other,  and  the  vaginal  walls  and  peritonaeum  united  with 
sutures.  The  anterior  vaginal  wall  is  to  be  next  circumcised,  and 
the  uterus  and  bladder  separated  up  to  the  peritonseum  with  the  dry 
dissector  or  the  finger.  1  prefer  not  to  open  into  the  peritoneal 
cavity  in  front  until  the  broad  ligaments  are  separated  from  the 
uterus  up  to  and  including  the  uterine  arteries.  The  vagina  may  be 
separated  from  the  uterus  with  the  knife,  scissors,  or  galvano-cautery. 
I  prefer  the  cautery. 


Fig.  189. — Cleveland  ligature  forceps. 


The  next  step  is  to  either  ligate  or  clamp  the  broad  ligaments  and 
separate  them  from  the  uterus.  If  ligation  is  determined  on,  it  is 
done  as  follows :  A  ligature  is  carried  around  the  lower  portion  of 
the  ligament  with  a  curved  needle,  Cleveland's  ligature  forceps  (Fig. 
189),  or  an  aneurism  needle,  securely  tied,  and  then  divided  close  up 


424 


DISEASES   OF   WOMEN. 


THE    CLAMP    OPEKATIOJSr    IN    VAGINAL    HYSTEKECTOMY. 
(Modified  from  Landau.) 


Fig.  190. — The  speculum  in  place,  the 
cervix  is  seized  and  drawn  down- 
ward, and  the  incision  begun  at 
the  junction  of  the  cervix  (C)  and 
the  vaginal  wall. 


Fig.  191. — The  cervix  having  been  severed 
from  the  vaginal  wall  all  around,  the  blad- 
der stripped  oif,  and  the  vesico-uterine 
pouch  opened,  the  body  is  caught  and 
drawn  out  through  this  anterior  opening. 


Fio.  192. — A  forceps,  guided  by  the 
fingers,  is  jiushcd  through  tiie 
pouch  of  Douglas. 


Fig.  103. — A  forceps  diaws  forward  into  view 
the  tube  (T).     F,  fundus  ;  C,  cervix. 


VAGINAL  HYSTERECTOMY. 


425 


Fig.  194. — Forceps  on  the  ovary  (0)  turns 
the  broad  ligament  forward.  The 
uterine  artery  is  clamped. 


Fig.  195. — The  tube  and  ovary  being^ 
rolled  forward,  the  ovarian  ar- 
tery is  clamped. 


Fig.  196. — The  uterine  artery  can 
be  clamped  as  soon  as  the 
vaginal  walls  are  freed  from 
the  cervi.x. 


Fig.  197. — Placing  the  gauze  (by  the  upper 
hand).  The  perinjeum  is  retracted  and 
the  forceps  spread  apart. 


to  the  uterus.  The  ends  of  the  ligature  should  be  cut  off  after  it 
is  tied  to  avoid  traction,  which  would  be  almost  sure  to  loosen  it. 
Successive  portions  of  the  ligament  are  treated  in  this  manner  until 
the  whole  is  separated  from  the  uterus.  The  other  broad  ligament 
is  treated  in  the  same  manner.  The  uterus,  being  now  free  from 
its  attachments,  is  removed. 

The  next  step  is  to  unite  the  peritonfeum  to  the  anterior  and 


426  DISEASES  OF   WOMEN. 

posterior  vaginal  walls  with  fine  catgut  sutures.  The  peritoneal 
cuts  should  now  be  sponged  clean.  One  end  of  each  suture  is  then 
cut  off  and  tlie  remaining  ends  are  tied  to  the  opposite  sutures,  thus 


Fig.  198. — Vaginal  hysterectomy  by  morceUement.     The  gray  lines  show  the  pieces  to  be 
removed  in  order,  each  being  shown  with  a  forceps  fast  to  it.     (Landau.) 

completely  closing  the  wound,  except  in  the  center,  where  space 
enough  is  left  to  admit  a  small  gauze  drain.  The  vagina  is  to  be 
loosely  packed  with  gauze,  and  the  operation  is  completed. 

Many  surgeons  prefer  silk  ligatures,  as  being  more  easily  handled 
and  more  certain  to  control  the  vessels ;  but  silk  is  objectionable  for 
various  reasons.  It  is  likely  to  cause  irritation  and  suppuration, 
and  a  longer  time  is  required  for  the  ligatures  to  come  away  or  be 
removed,  so  that  by  the  use  of  tliis  material  the  recovery  of  the 
patient  is  delayed. 

The  French  Method. — The  peculiarity  of  the  French  method  of 
performing  vaginal  hysterectomy  consists  in  the  use  of  pressure 
forceps  instead  of  ligatures  for  the  control  of  the  blood-vessels.  The 
circumcision  of  the  vagina  is  performed  in  the  n)anner  already  de- 
scribed, but  when  the  peritonauim  is  opened  the  forceps  are  applied 


MALIGNANT   DISEASE   OF   THE   UTERUS.  427 

to  the  lower  part  of  tlie  broad  ligaments.  The  uterus  is  then  retro- 
verted — although  some  surgeons  prefer  to  antevert  it — in  order  to 
bring  the  ligaments  nearer  to  the  operator,  and  then  the  upper  por- 
tions of  the  ligaments  are  clamped  with  forceps.  The  ligaments  are 
divided  between  the  forceps  and  the  uterus.  To  prevent  unlocking 
of  the  forceps  the  handles  are  tied  together.  Gauze  is  then  placed 
in  the  wound  between  the  forceps  to  act  as  a  drain,  and  either  gauze 
or  cotton  wrapped  around  tlie  handles  of  the  forceps  to  protect  the 
vulva.  Landau's  full  and  finely  illustrated  description  of  his  clamp 
operation  has  been  simplified  in  the  series  of  cuts  adapted  from  his 
work  (Figs.  190-198). 

Method  with  ElectriG  Ilcemostatic  Foi'ceps. — Whatever  may  be 
claimed  as  advantages  for  the  ligature,  even  the  modern  ligature, 
that  is  with  much  care  and  trouble  made  aseptic  and  can  be  left  in 
the  tissues,  has  its  faults  and  shortcomings.  The  catgut  ligature  is 
very  difficult  to  sterilize  and  keep  surgically  clean,  and  it  is  liable  to 
slip  and  permit  haemorrhage.  In  being  disposed  of  by  absorption, 
or  being  walled  in  or  encysted,  it  causes  more  or  less  irritation. 
Dead  animal  tissue,  though  sterile,  can  not  be  taken  care  of  in  a 
wound  without  causing  some  disturbance. 

Silk,  or  unspun  silk,  called  silkworm  gut,  properly  prepared, 
will  not  decompose,  and,  being  less  likely  than  catgut  to  slip,  has 
some  advantages,  but  is  more  objectionable  still  because  it  causes 
irritation,  and  in  the  effort  to  escape  or  be  thrown  out  enters  the 
abdominal  or  pelvic  viscera  and  does  great  damage.  There  are 
many  cases  recorded  of  serious  trouble  from  ligatures  of  this  kind 
long  after  recovery  from  operations. 

I^early  twenty  years  ago  I  learned  from  Dr.  Thomas  Keith  his 
method  of  treating  the  pedicle,  in  ovariotomy,  by  the  clamp  and 
cautery,  and  I  have  had  ample  opportunities  to  observe  that  the 
results  are  vastly  superior  to  those  obtained  by  any  other  method. 
Within  the  past  three  years  I  have  discovered  that  the  same  method 
of  closing  bleeding  vessels  is  applicable  in  all  surgical  operations. 
At  the  same  time  I  have  found  that  it  is  no  easy  matter  to  use  the 
means  which  give  such  excellent  results.  Naturally,  this  has  in- 
clined me  to  seek  some  simpler,  easier  way  of  accomplishing  the  same 
object — that  is,  to  arrest  bleeding  in  surgical  operation.  Hitherto 
the  difficulty  in  using  compression  and  heat  to  arrest  hgemorrhage 
has  occurred  in  the  management  of  the  heat  element. 

The  process  is  as  follows :  A  portion  of  the  end  of  the  vessel,  or 
mass  of  tissue  containing  bleeding  vessels,  is  seized  in  a  forceps  or 
clamp  and  firmly  compressed,  and  while  under  pressure  heat  is  ap- 


428 


DISEASES   OF   WOMEX. 


plied  to  the  instrument  to  desiccate  or  dry  the  parts  but  not  to  char 
them.  In  this  way  the  walls  of  the  arteries  become  united  and  haem- 
orrhage is  certainly  prevented.     Heretofore  the  heat  was  obtained 


Fig.  ]'■>'■>.  —  i^'iill-size  drawing  of  iiiuce  of  fic-sh  hccf-iiiusele  one  fourth  inch  thick  after 
being  seized  in  forccp  blades  two  minutes  with  current  on.  The  conij)resscd  place 
is  translucent  as  horn,  not  charred.     The  same  piece  is  shown  in  section. 


by  applying  a  heavy  cautery  iron  (heated  in  the  iire)  to  one  side  of 
the  clamp,  but  this  rendered  the  procedure  difficult  and  unsatisfac- 
tory, and  limited  it  to  the  treatment  of  the  pedicle  in  ovariotomy. 

With  the  determination  of  improving 
the  process  and  adapting  it  to  the  arrest  of 
hemorrhage  in  all  surgical  operations,  I 
have  employed  electricity  to  produce  the 
required  heat  and  devised  instruments  to 
meet  all  requirements.  I  have  now  per- 
fected the  method  so  that  I  believe  it  to  be 
worthy  of  the  attention  of  the  medical  pro- 
fession. 

The   advantages   which   may   be   fairly 


Fig.  2U0. — An  artery  from 
fresh  beef  closed  solidly 
by  author's  method  in  one 
half  minute.  Seen  in  per- 
spective and  in  section. 
Life  size. 


claimed  for  this  way  of  controlling  bleeding 


in  surgery  are,  that  it  is  certain  and  reliable 

in  closing  isolated  ves.sels  or  those  imbedded 

in  ma.sses  of  tissue,  like  an  ovarian  tumor  pedicle,  for  example,  or 

the   uterine  and   ovarian   arteries   in  the  bi-oad  ligament.     At  the 

same  time  that  bleeding  is  arre.stetl   all  lymphatics  are  sealed  up, 


MALIGNANT   DISEASE   OP   THE   UTERUS.  429 

whicli  prevents  septic  absorption.  Nerves  that  accompany  the  ves- 
sels are  immediately  and  completely  devitalized,  and  hence  there  are 
less  pain  and  irritation  in  the  stump.  The  heat  employed  sterilizes 
the  parts  involved,  and  therefore  the  operation  is  perfectly  aseptic. 
Of  these  many  advantages,  the  greatest,  I  believe,  is  that  it  leaves 
the  stump  of  a  pedicle  or  the  end  of  an  artery  in  a  condition  re- 
quiring the  least  reparatory  care,  so  that  recovery  is  more  prompt 
and  uneventful.  My  impression  is  that  the  ends  of  vessels  and  tis- 
sues of  pedicles  treated  in  this  way  become  first  hyd rated  and  then 
organized  (during  the  healing  process),  in  the  same  way  that  an 
inflammatory  exudate  upon  a  serous  membrane  becomes  vitalized.  I 
asked  Dr.  Keith  about  this.  He  said  that  he  did  not  know  exactly 
what  became  of  the  stump  of  the  pedicle  treated  in  this  way,  but  he 
did  know  very  surely  that  it  gave  no  trouble  or  anxiety  to  patients 
or  the  surgeon.  In  this  my  experience  fully  agrees  with  his.  I 
have  never  known  trouble  of  any  kind  to  occur  after  an  operation 
that  could  be  attributed  to  this  method  of  controlling  haemorrhage. 

Although  fully  satisfied  with  the  results  obtained  by  compression 
and  heat  as  a  liEemostatic,  I  have  long  been  annoyed  by  the  practi- 
cal difficulties  in  its  employment,  as  already  stated.  While  thinking 
of  how"  to  overcome  these  difficulties,  my  attention  was  called  to  the 
use  of  electricity  in  cooking  and  in  heating  laundry  smoothing  irons. 
It  then  occurred  to  me  to  adapt  the  same  heating  power  to  surgical 
instruments,  such  as  the  clamp  and  foi'ceps. 

My  requirements  in  this  regard  were  explained  to  Louis  M. 
Pignolet,  an  electrician  who  has  given  much  attention  to  electricity 
as  used  in  medicine  and  surgery.  He  at  once  took  up  the  study  of 
the  subject  with  enthusiasm  and  soon  produced  the  instruments  and 
appliances  required. 

The  following  is  Mr.  Pignolet's  description,  with  illustrations  of 
the  instruments  in  question  : 

"  The  construction  of  the  hseraostatic  forceps  is  plainly  shown  by 
the  illustration,  of  which  Fig.  201  is  a  side  view.  Fig.  202  a  section 
of  the  jaw  on  an  enlarged  scale,  and  Fig.  203  a  top  view  of  the 
chamber  in  the  jaw,  also  on  an  enlarged  scale,  showing  the  arrange- 
ment of  the  heating  wire.  The  chamber  is  formed  by  attaching  a 
flat  case  (A)  of  sheet  metal  to  the  inner  side  of  one  of  the  jaws  (B) 
of  an  ordinary  compression  forceps,  in  such  a  manner  as  to  form  a 
water-tight  chamber.  This  increases  the  size  of  the  jaw  but  little, 
as  the  case  is  less  than  an  eighth  of  an  inch  deep  and  has  the  same 
length  and  width  as  the  jaw,  so  that  the  instrument  appears  like  an 
ordinary  compression  forceps. 


430 


DISEASES  OF   WOMEN. 


"  The  wire  {C)  for  heating  the  sheet-metal  face  of  the  jaw  is  of 
platinum  or  other  suitable  metal,  and  zigzags  back  and  forth  from 
side  to  side  in  passing  through  the  chamber.     A  fireproof  material, 

which  is  also  an  electrical   insula- 
tor, separates  and  insulates  the  wire 
from    the   sides    of    the   chamber. 
The   space  between  the  wire  and 
the  back  of  the  chamber  is  several 
times   greater   than    that    between 
the  wire  and  the  front,  so  that  the 
heat  from  the  wire  can  pass  much 
more  easily  to   the   front   than   to 
the  back.     One  end  of  the  wire  is  electrical- 
ly  connected   to   the  instrument,  and  the 
other  to  a  copper  wire  (E)  passing  out  of 
the  chamber  throncrh  an  insulatino;  bushinof 
(F)  in  the  back  of  the  jaw.     The  copper 
wire  extends  back  to  the  handle  of  the  in- 
strument, and  is  insulated  by  a  waterproof 
covering.     Terminals  are  provided  at  the 
end  of  the  copper  wire  and  the  handle  of 
the  forceps  for   making   connections   with 
the  flexible  wires  or  cables  which  convey 
the  electric  current  to  the  instrument.    The 
jmth  of  the  current  is  through  the  copper 
wire,  the    wire    in    the    chamber,  and   one 
blade  of   the   forceps.      The  copper   wire 
and  the  blade  present  but  little  resistance 


Fig.  202. 


Fig.  201. 


Fig.  203. 


to  the  electricity  and  are  but  slightly  (if  a])i)reciably)  heated  by  the 
passage  of  the  current.  On  the  other  hand,  the  wire  in  the  cham- 
ber offers  considerable  resistance  to  the  current  and  is  heated  by  it 


MALIGNANT  DISEASE   OF  THE  UTERUS.  431 

to  a  greater  or  less  degree,  according  to  the  strength  of  the  current 
and  the  resistance  of  the  wire. 

"  By  this  method  of  construction  tlie  heat  is  concentrated  upon 
the  inner  surface  of  the  jaw  of  the  forceps  or  clamp — the  mechan- 
ism of  which  remains  precisely  the  same — and  but  little  is  expended 
uselessly  in  heating  the  other  parts  of  the  instrument.  The  elec- 
trical energy  necessary  for  heating  the  jaw  is  therefore  reduced  to 
the  smallest  possible  quantity,  and  varies  from  ten  to  thirty  watts, 
according  to  the  size  of  the  forceps. 

"  The  required  degree  of  heat,  which  varies  from  170°  to  19U° 
F.,  is  attained  very  quickly,  owing  to  the  closeness  of  the  heating 
wire  to  the  face  of  the  jaw  and  the  thinness  of  the  sheet  metal  com- 
posing the  face.  Furthermore,  the  instrument  can  be  sterilized  in 
the  same  manner  as  the  ordinary  forceps  without  damage. 

"  On  this  principle,  forceps  of  various  shapes,  from  the  largest  to 
the  smallest  sizes,  are  heated,  as  the  general  formation  of  the  instru- 
ments is  not  modified  by  the  heating  attachments. 

"  The  method  of  construction  described  is  advantageous,  for  it 
simplifies  the  instrument  by  dispensing  with  the  extra  copper  wire 
that  would  be  required  if  one  end  of  the  heating  wire  were  not 
connected  to  the  forceps ;  but  if  desired,  the  heating  wire  may  be 
connected  to  a  second  insulated  copper  wire  so  that  no  current 
would  flow  through  the  blades  of  the  forceps. 

"  The  heat  developed  in  the  forceps  depends  upon  the  strength 
of  the  electric  current  and  the  resistance  of  the  heating  wire.  The 
current  required  to  properly  heat  each  forceps  may  be  ascertained 
by  trial  and  marked  upon  the  instrument ;  or  all  the  forceps  (both 
large  and  small)  may  be  so  constructed  as  to  be  heated  to  the  re- 
quired degree  by  a  current  of  a  predetermined  strength,  by  suitably 
proportioning  the  resistance  of  the  heating  wire.  A  small  ampere 
meter  included  in  the  electric  circuit  measures  the  current  re- 
ceived by  the  forceps,  and  enables  the  current  to  be  i-egulated  to 
suit  by  means  of  a  rheostat  or  other  controlling  device.  The  heat 
of  the  jaw  is  ihus  controlled  with  certainty,  as  the  current  required 
by  each  forceps  is  known,  as  explained  above. 

"  The  length  of  time  during  which  the  forceps  should  be  heated 
varies  from  thirty  seconds  to  two  minutes  and  a  half,  depending 
upon  the  thickness  of  the  tissues  compressed  between  the  jaws  of 
the  instrument.  It  is  advantageous  to  give  the  forceps  a  slight  ex- 
cess of  current  for  a  few  seconds  at  the  commencement,  as  this 
hastens  the  desiccation  of  the  tissues  and  shortens  the  time  of  appli- 
cation.    If,  for  example,  ten  amperes  be  the  current  required  to 


432  DISEASES   OP   WOMEN. 

lieat  the  forceps  to  the  proper  degree,  start  with  twelve  amperes  and 
decrease  to  ten  amperes  after  the  lapse  of  a  quarter  or  a  third  of 
the  time  during  which  the  current  is  to  be  applied. 

"  As  the  forceps  require  less  electrical  energy  than  the  average 
cautery  electrode,  the  current  from  a  small  storage  battery  or  a 
suitaljle  primary  battery,  such  as  the  excellent  battery  of  Dr.  Byrne, 
can  be  used  for  heating  them,  but  the  current  from  electric-light 
mains  is  preferable,  as  it  is  not  subject  to  failure,  and  the  care  and 
attention  necessary  to  keep  a  battery  in  working  order  are  avoided. 

''  Alternating  current  of  the  pressure  used  for  lighting  buildings 
can  be  converted  into  a  current  of  lower  pressure  adapted  for  the 
forceps,  as  well  as  cautery  knives  and  examining  lamps,  by  means 
of  a  small  transformer  capable  of  giving  current  of  different 
strengths  and  pressures.  The  current  is  generated  in  a  coil  of  wire 
called  the  '  secondary '  by  the  inductive  action  of  the  lighting  cur- 
rent passing  through  an  adjacent  coil  called  the  '  primary.'  The 
two  coils  are  carefully  insulated  from  each  other,  so  that  there  is  no 
danger  from  the  comparatively  high-pressure  lighting  current,  as  it 
can  not  pass  from  the  primary  to  the  secondary.  A  further  ad- 
vantage of  the  transformer  is  that  it  increases  the  quantity  of  cur- 
rent available  as  well  as  reduces  the  pressure,  so  that  a  current  of 
large  quantity  but  low  pressure  can  be  obtained  without  overloading 
the  smallest  electric-light  wire  used. 

"  The  pressure  is  varied  to  suit  the  forceps  or  other  device  by 
cutting  a  sufficient  number  of  the  turns  of  secondary  wire  in  or 
out  of  the  circuit  by  a  switch,  or  by  altering  the  strength  of  the 
inductive  action  upon  the  secondary  coil  by  moving  it  to  a  place 
where  the  action  is  stronger  or  weaker,  as  a  greater  or  less  pressure 
is  desired. 

"  A  convenient  form  of  transformer,  constructed  according  to  the 
latter  metliod,  is  illustrated  by  Fig.  204-.  The  flexible  cable  convey- 
ing the  electric-light  current  is  connected  to  the  binding  posts.  A,  the 
cautery  electrode  to  B,  and  the  incandescent  lamp  to  C.  The  cur- 
rent is  regulated  l)y  sliding  the  knobs  (L)  and  E)  which  control  the 
cautery  and  lamp  coils  respectively  toward  the  center  of  the  instru- 
ment to  increase  the  pressure  and  quantity,  and  vice  versa.  If  the 
electric-light  current  be  continuous,  it  can  be  converted  into  an 
alternating  current  suital)le  for  operating  a  transformer  by  a  small 
rotary  converter. 

"  The  current  from  the  electric  mains  can  be  used  directly,  with- 
out the  intervention  of  a  transformer,  if  it  be  controlled  by  a  rhe- 
ostat;  but  this  is  not  advisable,  for  the  high  pressure  of  the  current 


MALIGNANT   DISEASE   OP   THE  UTERUS. 


4^3 


might  cause  a  dangerous  arc  or  a  shock  under  certain  conditions 
arising  from  some  disarrangement  of  the  apparatus. 

"  A  portable  generator  of  electricity  which  would  be  as  reliable  as 
the  ordinai*y  dynamo  is  an  important  requirement  for  medical  and 


Fig.  204. — Transformer  for  heating  hfemostatic  forceps  and  lighting  small  lamps. 


surgical  purposes  where  an  electric-light  current  is  not  available. 
This  necessity  led  to  the  construction  of  a  small  hand-driven  dynamo 
for  use  in  such  cases. 

"  The  machine  is  represented  by  Fig.  205,  and  is  a  convenient 
and  reliable  means  for  heating  the  haemostatic  forceps  as  well  as 
cautery  electrodes,  and  for  lighting  small  incandescent  lamps.  It 
requires  no  attention,  except  an  occasional  oiling,  and  is  less  liable  to 
derangement  than  an  ordinary  electric-light  dynamo.  The  dynamo, 
which  has  a  very  high  efficiency  for  a  small  machine,  was  specially 
designed  for  the  purpose,  and  is  driven  by  sprocket  wheels  and 
chains,  as  shown  by  the  illustration.  The  armature  is  provided 
with  two  separate  windings,  each  with  its  individual  commutator  and 
brushes  for  collecting  the  current.  Each  winding  is  capable  of  gen- 
erating a  current  of  fifteen  amperes  at  a  pressure  of  from  one  and  a 
29 


434 


DISEASES  OF  WOMEN. 


half  to  three  volts,  according  to  the  speed  of  the  armature,  A 
switch  is  provided  for  connecting  the  windings  together  in  parallel, 
to  double  the  quantity  of  the  current,  or  in  series,  to  double  the 
pressure.  In  this  way  a  current  may  be  obtained  of  lai-ge  quantity 
and  low  pressure,  such  as  is  required  for  cautery  electrodes,  as  well 
as  the  current  of  smaller  quantity  and  higher  pressure  needed  for 
small  lamps  and  other  apparatus.     The  machine  will  furnish  cur- 


FiG.  205. — Hand-driven  dynamo  for  heating  hsemostatic  forceps  and  cautery  electrodes. 


rent  of  any  pressure  from  one  and  a  half  to  six  volts,  and  even 
slightly  beyond  these  limits,  which  is  sufficient  for  all  ordinary  uses. 

"  A  small  voltmeter,  or  an  inexpensive  galvanometer,  connected  to 
the  circuit  enables  one  to  keep  the  current  at  any  desired  strength." 

Vaginal  hysterectomy  offers  superior  opportunities  for  the  use 
of  the  haemostatic  forceps  in  arresting  haemorrhage.  I  have  tried 
every  known  method  of  doing  this  operation  and  found  them  all 
objectionable,  and  so  I  was  led  to  do  the  operation  as  follows : 

The  vagina  is  divided  all  round  the  cervix  uteri  with  the  cautery 
knife.  The  bladder  is  separated  from  the  uterus  and  the  perito- 
naeum opened  in  front  and  behind  in  the  usual  way.  The  lower 
portion  of  the  broad  ligament  is  then  seized  with  the  compression 
forceps  as  close  to  the  uterus  as  possible  and  the  heat  turned  on. 
The  compression  is  increased  while  the  heat  is  being  applied.  A 
little  practice  is  needed  in  order  to  know  the  degree  of  heat  that  is 


PLATE  11. 


()'i  >e,  the  i< 

a!i<i   til  '   I   '  ir  up  as  the 

PLATE   11.  ^ 

Upper  figure.     See  page  435. 

Yaginal  Hysterectomy  with  the  Authok's  Haemostatic 
Cauteky  Forceps. 

206. — Cautery  incisi- 

On  the  right  of  the  picture  the  uterine  and  vaginal  arteries  are 
shown ;  on  the  left,  the  blades  in  their  first  seizure  grasp  the  uterine 
artery  close  to  the  cervix,  at  a  safe  distance  from  the  ureter,  which 
is  represented  by  a  black  dot.  .apressi</ 


)-:,  /--<  Lower  figure.    See  page  435.   trolling    hsemorrhage 

The  first  seizure  having  been  loosened  and  the  compressed 
lower  half  of  the  broad  ligament  freed  with  the  scissors,  the  forceps 
takes  a  second  grasp  higher  up.  To  remove  the  tube  and  ovary  on 
this  side  with  the  uterus,  this  second  hold  would  be  taken  along  the 
pelvic  side  of  the  broad  ligament. 

CCpr> 


»/jl     Utc 


h  the  ppv  electr:  uade  and 


ture ;  in  fact,  it  tak 


I'l.AT 


/' 


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MALIGNANT  DISEASE   OF  THE   UTERUS. 


435 


Fig.  206. — Cautery  incisions  about 
the  cervix. 


being  used  and  the  length  of  time  that  it  should  be  continued. 
When  one  is  doubtful  about  this,  the  forceps  may  be  removed  and 
the  parts  inspected,  and,  if  need  be,  the  forceps  should  be  reapplied 
and  the  heat  continued  long  enough  to  obtain  the  desired  effect. 
The  ligament  is  divided  with  knife  or  scissors  between  the  forceps 
and  the  uterus  as  far  up  as  the 
vessels  have  been  closed.  The 
lower  portion  of  the  ligament  on 
the  other  side  is  treated  in  the 
same  way.  The  uterus  is  drawn 
down,  and  the  remaining  portions 
of  the  ligaments  are  treated  in 
sections  until  the  uterus  is  com- 
pletely made  free.  The  operation 
may  be  briefly  described  by  say- 
ing that  it  is  performed  in  the  same  way  as  when  forceps  is  used  to 
control  the  bleeding,  with  the  difference  that  instead  of  leaving  the 
forceps  on  long  enough  for  the  compression  alone  to  arrest  the 
haemorrhage,  the  heat  completes  the  hsemostasis  and  the  forceps  is 

removed  at  once. 
Peritoneum.  jjj    controlling    hssmorrhage 

from  small  arteries  my  observa- 
tions have  been  limited  to  such 
operations  as  amputation  of  the 
mammary  gland  and  small  ves- 
sels in  divided  adhesions  in  ab- 
dominal operations.  The  for- 
ceps employed  for  this  purpose 
is  in  form  the  same  as  the  ordi- 
nary artery  forceps,  and  is  used 
in  the  same  way.  The  artery  is 
seized  and  held  firmly,  and  the 
electrical  connection  made  and 
continued  until  the  end  of  the 
compressed  vessel  is  desiccated. 
This  takes  very  little  more 
time  than  applying  a  ligature ;  in  fact,  it  takes  less  time  when  the 
vessel  is  in  a  deep  cavity  and  not  easy  to  get  at.  In  the  manage- 
ment of  small  bleeding  vessels  in  the  abdomen  or  down  in  the  pel- 
vic cavity  this  electrically  heated  forceps  is  very  useful  and  con- 
venient, and  saves  much  time,  trouble,  and  anxiety. 

Up  to  the  present  time  I  have  not  practiced  this  method  of  con- 


-Snture  through 
peri  ton  feu  m 
:■•).     and  through 
KZif:-     vaginal  wall 
§:^^.-      above  cau- 
'"'      '"      terized 
edge. 


Fig.  20*7. — Diagram  of  vagina  and  wound 
after  removal  of  uterus.  The  suture 
passes  through  the  peritonEeum  and  the 
vaginal  wall  beyond  the  cautery  cut,  and 
is  tied ;  then  is  tied  to  its  fellow  on  the 
opposite  wall. 


436  DISEASES  OF   WOMEN. 

trolling  the  hsemorrhage  in  doing  abdominal  hysterectomy,  but  I  am 
confident  that  it  can  be  employed  satisfactorily  in  that  operation. 

After-treatment. — The  after-treatment  will  depend  upon  what 
method  of  operating  has  been  selected.  In  all  cases  rest  and,  if 
necessary,  a  cathartic  are  to  be  prescribed.  If  pain  is  marked  and 
the  stomach  irritable,  opium  and  warm  water  may  be  given  by  the 
rectum.  For  the  first  few  days  the  food  should  be  liuid ;  on  the 
third  day  the  bowels  should  be  moved  by  a  saline  cathartic,  and  by 
an  enema  of  glycerin  and  water.  The  gauze  packing  is  left  in  the 
vagina  for  five  or  six  days  by  most  operators.  If  the  operation  has 
been  done  with  ligatures,  I  prefer  to  change  the  gauze  at  the  end  of 
forty-eight  hours.  When  forceps  are  used  I  remove  the  gauze  at 
the  end  of  thirty-six  or  forty-eight  hours,  and  introduce  a  gauze 
drain,  which  is  to  be  changed  at  the  end  of  two  or  three  days,  and 
replaced  if  there  is  much  suppuration.  If  the  wound  unites  without 
much  suppuration,  a  douche  can  be  used,  but  without  the  least  force, 
for  five  or  six  days,  and  continued  daily  until  all  the  discharges 
have  ceased. 

After-treatment  of  cases  operated  upon  by  my  method  :  The 
vagina  is  loosely  packed  with  gauze,  which  is  removed  at  the  end  of 
forty-eight  hours,  and  if  there  is  any  discharge  it  is  not  replaced. 
After  the  fourth  or  fifth  day  the  vaginal  douche  of  borax  and  water 
may  be  used,  and  repeated  daily  if  there  is  any  discharge.  At  the 
end  of  a  week  the  wound  is,  as  a  rule,  completely  healed,  and  no 
further  local  treatment  is  necessary. 

SARCOMA    OF    THE    UTERUS. 

Fibroplastic  tumors,  or  "  recurrent  fibroids,"  are  neoplasms  of 
the  embryonic  tissue  type  whose  seat  is  usually  in  the  body  of  the 
uterus. 

Pathology. — The  connective  tissue  is  the  origin  of  uterine  sar- 
coma; and  immediately  beneath  the  epithelium  this  tissue  forms 
nodules  or  ridges  which  bulge  out  the  softened  and  somewhat  dis- 
integrated mucosa  into  the  uterine  cavity. 

Since  the  projections  are  often  polypoidal,  pedunculated,  soft, 
and  medullary  in  consistence,  rapid  in  their  growth,  and  vascular,  it 
is  easy  to  see  how  they  can  be  mistaken  for  carcinoma.  Indeed, 
Klebs  has  found  a  profuse  epitiielial  growth  upon  sarcomatous  nod- 
ules of  the  uterus  and  then  the  growths  seem  to  have  joined. 

The  uterus  may  be  greatly  distended  by  the  fungus-like  growth. 

When  the  mucous  membrane  is  wholly  disintegrated,  the  uterus 


A 


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MALIGNANT  DISEASE  OF  THE  UTERUS.  437 

may  be  perforated,  and  in  rare  instances  the  sarcoma  may  prolifer- 
ate out  through  the  abdomen. 

In  other  cases  the  growth  is  deeper,  less  diffuse,  and  more  nodu- 
lar. It  begins  anywhere  in  the  uterine  tissue  between  the  submu- 
cous layer  and  the  peritoneal  investment  and  forms  a  hard,  roundish 
mass  like  a  fibroid.  This  may  assume  a  fungoid  or  polypoid  form 
and  hang  down  in  the  uterine  cavity ;  as  in  cancer,  so  here,  the  soft 
may  be  a  later  stage  of  the  hard  sarcoma. 

Possibly  a  degenerating  fibroid  of  the  uterus  may  be  associated 
with  a  sarcoma  ;  or,  as  it  then  would  be  called,  a  fibro-sarcoma. 

As  to  the  effects,  the  vagina,  peritonaeum.  Fallopian  tubes,  and 
ovaries  may  be  invaded  by  sarcomatous  masses. 

The  uterus  is  often  inverted,  either  from  an  easily  dilated  cervix 
or  from  weakening  or  palsy  of  the  uterine  muscle. 

Symptomatology . — The  classical  symptoms  of  malignant  disease — 
pain,  haemorrhage,  and  discharge — are  met  in  cases  of  sarcoma  uteri. 

Pain,  however,  occurs  late,  if  at  all,  and  seems  to  have  often 
been  confounded  with  uterine  tenesmus,  which  is  a  common  symp- 
tom. At  times  there  may  be  severe  pain  from  pressure  on  the  rec- 
tum and  bladder. 

Menorrhagia  is  an  early  symptom ;  or  if  the  disease  is  in  those 
who  have  passed  the  menopause,  menstruation  seems  to  have  re- 
turned. Later,  there  is  a  discharge  resembling  the  rice-water  stools 
of  cholera  which  is  only  faintly  suggestive  of  the  cancerous  odor. 
But  as  the  neoplasm  ulcerates,  the  discharge  is  as  fetid  as  that  of 
carcinoma,  and  in  it  are  pale-gray  shreds,  which  upon  microscopical 
examination  at  once  reveal  the  true  nature  of  the  growth. 

A  cachexia  is  very  slowly  and  gradually  developed,  yet  finally  it 
is  as  marked  as  in  cancer. 

Physical  Signs. — Palpation  reveals  a  soft,  friable,  pedunculated 
tumor  which  may  be  felt  to  spring  from  the  body  of  the  uterus. 
The  OS,  through  which  this  tumor  is  forced,  is  dilated,  softened,  and 
irregular.  The  finger  or  the  sponge-tent  may  be  used  to  dilate  the 
cervical  canal  when  the  mass  has  not  yet  made  its  way  down  to  the 
OS  internum. 

Bimanual  palpation  shows  the  uterus  to  be  large,  sometimes 
reaching  halfway  to  the  umbilicus,  and  oftentimes  as  irregular  as 
when  the  seat  of  fibromata. 

The  sound  shows  the  extent  of  the  enlargements ;  its  use  causes 
intense  monorrhagia. 

The  curette  is  useful  to  obtain  scrapings  for  microscopic  exami- 
nation. 


438  DISEASES  OF  WOMEN. 

Diagnosis. — Sarcoma  may  be  mistaken  for  carcinoma ;  but  in 
the  latter  disease  pain  is  a  far  more  frequent,  early,  and  severe 
symptom ;  the  discharge  is  fetid  almost  from  the  very  onset ;  the 
cervix  is  most  difficult  to  dilate  with  a  sponge-tent;  the  constitu- 
tional symptoms  are  more  severe ;  and  the  duration  of  the  disease 
is  rarely  over  a  year.  These  symptoms  are  in  contrast  with  what' 
occurs  in  sarcoma. 

Finally,  a  microscopic  examination  of  some  of  the  scrapings  will 
always  be  necessary  before  determining  the  diagnosis. 

Prognosis. — Although  a  patient  with  sarcoma  of  the  uterus  lives 
on  the  average  three  or  four  years  after  the  tumor  is  fairly  devel- 
oped, yet  the  outlook  for  ultimate  recovery  is  most  grave,  all  cases 
slowly  but  surely  tending  toward  a  fatal  issue. 

Sarcoma  tends  to  reappear  after  most  careful  removal,  although 
the  time  elapsing  between  removal  and  recurrence  is  much  longer 
than  in  the  case  of  carcinoma. 

The  prognosis  will  greatly  depend  upon  an  examination  of  the 
scrapings:  when  these  show  scanty  stroma  with  an  abundance  of 
cell  elements,  the  course  will  probably  be  as  rapid  as  that  of  enceph- 
aloid  cancer ;  but  when  the  cells  are  few  and  the  fibrous  tissue  is 
abundant,  life  may  be  prolonged  for  six  or  eight  years. 

Among  the  complications  are  septicsemia,  anaemia,  peritonitis, 
and  sarcomatous  nodules  in  adjacent  organs. 

Causation. — Age  is  the  chief  predisposing  cause ;  half  of  all  the 
cases  occur  between  the  ages  of  forty  and  fifty,  and  before  thirty  or 
after  sixty  sarcoma  is  extremely  rare. 

In  cancer  I  referred  to  the  occurrence  of  the  disease  in  those 
who  had  borne  many  children  ;  but  sarcoma  seems  to  develop  in 
sterile  wombs  in  nearly  fifty  per  cent  of  the  recorded  cases. 

It  is  a  mooted  question  whether  traumatism  and  uterine  inflam- 
mation have  any  influence  in  the  causation  of  sarcomata. 

Treatment. — When  pedunculated  tumors  project  into  or  out 
through  the  cervix,  the  sharp  spoon  or  the  galvano-cautery,  or  even 
the  finger-nail,  may  be  used  to  remove  them.  Then  carbolic  or 
nitric  acid  may  be  applied  to  the  base  of  the  tumor. 

When  the  growth  is  not  sessile  but  apparently  superficial,  thor- 
ough curetting  and  the  application  of  nitric  or  carbolic  acid  are 
advocated. 

Deep  sarcomata  can  only  be  treated  by  extirpation  of  the  uterus. 


CHAPTER  XXIII. 

THE    MENOPAUSE. 

The  menopause  marks  the  dividing  line  between  middle  life  and 
the  beginning  of  old  age. 

The  permanent  suspension  of  the  menstrual  function  is  known 
by  several  names,  such  as  critical  time,  climacteric  or  climacteria, 
turn  of  life,  and  menopause,  the  latter  term  being  the  most  express- 
ive and  preferable. 

The  natural  history  of  the  final  cessation  of  menstruation  varies 
so  much  in  different  individuals  that  it  is  difficult  to  accurately  give 
a  tj^pical  account  of  it.  The  time  when  it  occurs  ranges  from  forty 
to  fifty  years  of  age,  the  average  in  this  country  being  about  forty- 
five.  The  menopause  coming  early  or  late  depends  apparently  upon 
the  delicacy  or  health  and  vigor  of  individuals.  There  is  a  popular 
idea  that  those  who  begin  early  should  stop  early,  but,  according  to 
my  observations,  those  who  reach  the  period  of  puberty  betimes 
because  of  good  health  and  strength,  and  who  continue  healthy,  are 
likely  to  maintain  the  menstrual  function  later  in  life,  providing 
that  all  the  sexual  functions  are  normally  exercised  throughout 
middle  life. 

The  question  has  been  raised  as  to  whether  celibates  do  not  reach 
the  menopause  earlier  than  fruitful  women,  but  I  have  not  yet  ob- 
tained facts  sufficient  to  answer  this  definitely.  In  women  of  good 
health,  to  whom  the  change  comes  without  complications,  I  have 
observed  that  in  one  class  the  menstrual  flow  becomes  less  free  and 
shorter  in  duration,  then  a  period  may  be  missed,  to  be  followed  by 
a  recurrence  or  two,  and  then  it  finally  ends.  In  others  the  inter- 
menstrual period  is  lengthened  to  five  or  six  weeks,  and  the  flow 
when  it  does  come  is  free,  often  profuse,  and  lasts  longer  than 
usual.  The  time  from  the  waning  until  the  final  cessation  of  men- 
struation varies  from  six  months  to  two  years  or  longer. 

The  menopause  being  an  event  which  is  natural  to  woman,  there 
is  nothing  in  its  occurrence  which  should  cause  ill  health ;  still  it 
is  attended  by  certain  phenomena  indicating  special  modifications 

439 


440  DISEASES  OF  WOMEN. 

of  the  organization  which  disturb  the  comfort  and  general  activity 
of  the  most  health}^  women,  though  not  to  a  degree  that  can  be 
called  ill  health.  Many  increase  in  flesh,  become  less  inclined  to 
mental  and  physical  activity,  and  show  signs  of  excrementitious 
plethora.  There  is  nsually  constipation,  often  due  to  deranged  secre- 
tions, and  the  nervous  and  vascular  systems  are  more  or  less  dis- 
turbed. Very  often  functional  heart  trouble,  irregular  action  and 
palpitation  of  the  heart,  with  a  feeling  of  impending  danger,  are 
the  common  symptoms.  These  are  frequently  associated  with  inter- 
costal neuralgia  of  the  left  side.  Grave  apprehensions  on  the  part 
of  the  patient  are  excited  by  these  symptoms. 

Similar  indications  appear  in  amenorrhoea  in  young  subjects. 
This  points  to  the  fact  that  cessation  of  the  menses  has  a  peculiar 
influence  upon  the  innervation  of  the  circulatory  system.  The 
flushings  of  the  face,  "  hot  flashes,"  from  vaso-motor  derangement, 
annoy  them  sometimes  very  much.  Fullness  of  the  head  and  occa- 
sionally headache  and  drowsiness  during  the  day,  and  disturbed 
sleep  at  night,  are  frequently  noticed.  In  other  cases  the  appetite 
fails  slightly,  and  there  is  no  gain  in  weight,  perhaps  a  slight  loss  of 
flesh.  The  same  disturbed  circulation  is  generally  present,  but  there 
is,  on  the  other  hand,  increased  nerve  excitability.  Complaint  is 
made  of  restlessness,  and  a  number  of  minor  symptoms,  such  as  im- 
paired memory  from  lack  of  interest  and  concentration,  are  observed 
and  often  dreaded.  These  are  the  usual  symptoms  which  attend 
the  menopause  in  healthy  women  living  under  favorable  circum- 
stances. 

Comparing  the  menopause  with  puberty  shows  that  they  are 
almost  exact  opposites,  the  one  being  a  development  of  structure 
and  establishment  of  function,  the  other  a  decay  of  structure  and 
suspension  of  function.  One  marked  difference  is  noticeable  :  men- 
struation is  complete  and  perfect  from  the  beginning.  Established 
after  all  the  structural  conditions  are  matured,  it  is  maintained  in 
full  effect.  The  menopause  comes  gradually  as  the  decline  of  the 
structures  progresses. 

Atrophy  of  the  sexual  organs  from  impaired  nutrition  is  the 
anatomical  change  that  directly  leads  up  to  the  menopause.  The 
ovaries,  having  all  along  been  breaking  down  to  a  certain  extent,  at 
each  ovulation  arrive  at  a  condition  of  senile  atrophy,  and  no  longer 
exert  their  full  influence  in  the  economy.  There  is  not  now  the 
demand  for  so  large  a  blood  supply,  and  the  uterus  shares  in  the 
lowered  nutrition.  The  ovaries  first  arrive  at  the  stage  of  atrophy 
through  a  gradual  breaking  down  of  the  tissues,  which  causes  in- 


THE  MENOPAUSE.  441 

competence.  This,  no  doubt,  is  the  most  important  factor  in  the 
causation  of  the  menopause,  but  it  is  only  one  of  several.  There  is, 
furthermore,  an  atrophy  or  lowered  nutrition  of  the  spinal  centers 
and  organic  nerves  which  govern  the  sexual  organs  at  this  time  of 
life,  and  the  brain  also  to  some  extent  withdraws  its  influence  from 
them.  Simultaneously  with  these  changes  the  uterus  becomes  atro- 
phied, the  degeneration  progressing  slowly.  There  is  at  first  anae- 
mia of  the  uterus,  which  is  apparent  in  the  pallor  of  the  vaginal 
and  cervical  mucous  membranes.  The  whole  organ  gradually  di- 
minishes, until  finally  it  approximates  to  the  infantile  in  form  and 
size,  although  the  senile  uterus  is  a  little  larger  than  that  of  a  child. 
When  these  anatomical  changes  are  completed  menstruation  ends, 
but  the  atrophic  diminution  continues  for  some  time  after  the 
menopause. 

Leith  Napier,  in  his  elaborate  work  on  the  Menopause,  gives  as 
the  cause  the  general  atrophic  condition  which  comes  on  in  senility. 
I  have  always  taught  that  it  was  the  result  of  the  atrophic  changes 
in  the  sexual  system  and  in  the  nerve  centers  which  preside  over  it. 
I  do  not  believe,  as  Napier  claims,  that  it  is  due  to  the  general  atro- 
phic condition  of  the  entire  organization. 

As  already  stated,  the  menopause  occurs  in  consequence  of  a  de- 
cline or  atrophy  of  the  sexual  organs,  nutritive  supply,  and  innerva- 
tion ;  hence  there  should  be  a  harmonious  falling  off  in  all  the 
structures  concerned  in  the  functions  of  the  sexual  organs.  When 
that  is  the  case  the  change  of  life  is  free  from  anything  that  re- 
quires the  attention  of  the  physician ;  but  when  the  nutritive 
changes  which  precede  the  suspension  of  the  menstrual  function 
progress  faster  in  one  portion  of  the  economy  than  in  another, 
morbid  disturbances  arise.  It  follows  that  certain  affections  which 
occur  at  the  menopause  are  due  to  deranged  nutrition  and  prema- 
ture deterioration  of  that  portion  of  the  cerebro-spinal  sympathetic 
systems  which  govern  the  sexual  organs.  Others  are  due  to  prema- 
ture or  delayed  atrophic  or  destructive  changes  in  the  sexual  organs 
themselves. 

Varying  forms  of  derangements  may  arise  from  these  causes. 
For  example  :  Withdrawal  of  the  mental  influence  may  cause  sup- 
pression of  the  menses  before  the  sexual  organs  are  atrophied,  and 
an  over-devotion  to  matters  sexual  may  cause  menstruation  to  con- 
tinue in  an  imperfect  way  after  the  wasting  of  the  uterus  and  ova- 
ries takes  place  to  some  extent.  On  the  other  hand,  degeneration 
of  the  ovaries  and  uterus  may  cause  suppression  of  the  menses 
while  the  cerebro-spinal  structures  may  still  be  perfect  and  function- 


442  DISEASES  OF  WOMEN. 

ally  active.  Certain  diseases  of  the  sexual  organs  may  keep  np  a 
modified  form  of  menstruation  after  the  nutrition  of  the  nervous 
system  has  begun  to  decline.  When  this  latter  condition  prevails, 
the  nervous  and  nutritive  systems  have  a  drain  imposed  upon  them 
which  they  are  incapable  of  sustaining,  and  consequently  suffer  de- 
rangement. On  the  contrary,  while  the  nutritive  and  nervous 
systems  remain  healthy  and  active  there  is  a  necessit}'^  for  men- 
struation, and  if  (owing  to  atrophy  or  malnutrition  of  the  sexual 
organs)  menstruation  is  suspended  the  general  economy  is  sure  to 
be  deranged. 

The  derangements  and  disorders  incident  to  the  menopause  may 
be  classified,  according  to  the  way  in  which  they  are  manifested, 
under  three  heads  :  premature  or  delayed  menopause,  and  constitu- 
tional derangements  accompanying  or  following  the  menopause. 
The  latter  is  subdivided  into  nutritive  and  nervous  disorders  conse- 
quent upon  the  suspension  or  undue  continuance  of  this  function. 

Premature  Menopause. — The  function  of  menstruation  may  be 
suddenly  suspended,  or  it  may  gradually  subside  and  end  completely 
at  too  early  an  age.  The  abrupt  ending  of  menstruation  being  the 
most  unnatural,  gives  rise  to  the  greater  disturbance  of  the  general 
health.  The  causes  of  premature  menopause  are  of  two  classes  : 
diseases  and  injuries  of  the  sexual  organs,  and  diseases  of  the  nutri- 
tive and  nervous  systems.  By  recalling  the  conditions  necessary  to 
normal  menstruation,  given  in  the  chapter  on  Menstruation,  it  will 
be  seen  how  these  causes  are  operative.  The  disorders  of  the 
sexual  organs  which  cause  a  premature  menopause  are  degenerative 
disease  of  both  ovaries,  double  ovariotomy,  and  loss  of  the  Titerns 
or  injuries  to  it,  which  lead  to  its  premature  atrophy.  Of  the  lat- 
ter, the  most  conspicuous  are  hysterectomy,  the  ovaries  being  left : 
puerperal  metritis,  which  results  in  superinvolution  ;  and  extensive 
lacerations  followed  by  the  formation  of  much  scar  tissue.  Opera- 
tions for  the  relief  of  deep  bilateral  lacerations,  requiring  removal  of 
large  portions  of  uterine  tissue,  may  lead  to  atrophy.  This  has  been 
noticed  by  several  observers  in  late  years. 

Removal  of  the  ovaries  may  be  taken  as  the  principal  cause  of 
abrupt  menopause.  Ovaries  that  are  slowly  destroyed  by  disease 
bring  about  the  menopause  more  gradually.  This  is  made  quite 
apparent  from  the  clinical  facts,  that  those  who  have  well-defined 
destructive  diseases  of  the  ovaries  menstruate  imperfectly  for  some 
time,  and  suffer  very  little  from  the  menopause  when  it  is  completed 
by  the  removal  of  the  ovaries  and  tubes,  because  the  change  comes 
more  like  the  natural  way.     Premature  menopause  caused  abruptly 


THE  MENOPAUSE.  443- 

by  removal  of  functionally  competent  ovaries  and  tuljes,  removal  of 
the  uterus,  or  diseases  and  injuries  of  the  uterus,  which  incapacitate 
that  organ  for  performing  its  functions,  give  rise  to  such  marked 
derangement  of  the  general  health  as  to  demand  special  considera- 
tion. Fortunately,  the  ovaries  are  not  sacrificed  so  often  novs^  as  in 
the  near  past,  when  they  were  removed  in  the  vain  hope  of  reliev- 
ing certain  neuroses,  incurable  dysmenorrhoea,  and  uterine  fibrom- 
ata. It  is  strange  that  Napier  makes  no  allusion  to  induced  meno- 
pause. 

Syonptoms. — The  effect  of  the  removal  of  the  normal  ovaries  in 
middle  life  is  to  derange  the  nervous,  nutritive,  and  circulatory 
systems.  The  clinical  history  appears  in  many  cases  to  partake  of 
the  characteristics  of  neurasthenia,  nervous  irritability,  and  derange- 
ment of  the  emotions.  Great  muscular  and  nerve  weakness,  indi- 
cated by  continual  weariness,  soon  appears.  In  some  there  is  decided 
nervous  irritability  (that  which  is  known  as  nervousness),  with  a  dis- 
position to  try  to  do  much,  but  who  become  easily  fatigued.  There 
is  mental  depression,  indicated  by  sighing  and  lamenting  over  real 
pains  and  debility,  and  imaginary  evils  that  are  present  or  impending. 
Much  of  this  depression  and  emotional  disturbanced  comes  from  a 
consciousness  of  being  sexually  impotent.  The  nervous  systemic 
disturbance  is  manifested  by  headache,  pain  in  the  neck  and  back, 
pain  in  the  limbs,  tenderness  of  the  skin,  strange  wandering  pains,. 
and  queer  feelings  in  the  head  and  elsewhere.  These  symptoms 
are  the  same  in  kind  as  those  found  in  connection  with  the  meno- 
pause at  the  right  age  for  it ;  but  in  cases  of  premature  arrest  of 
menstruation  the  disturbances,  mental  and  physical,  are  greatly  ex- 
aggerated. 

Dr.  Savage  *  calls  attention  to  some  of  the  mental  troubles  com- 
plained of  by  such  patients.  They  fancy,  he  says,  that  something 
has  burst  in  the  head  or  womb ;  have  a  sensation  as  if  hot  blood 
were  over  the  brain,  and  a  feeling  of  deadness  or  emptiness.  With 
the  passing  away  of  the  sexual  functions,  querulousness,  jealousy, 
and  a  fancy  that  their  husbands  no  longer  care  for  them,  not  infre- 
quently occur.  All  of  these  symptoms  I  have  frequently  observed 
in  my  own  practice.  There  are  also  pelvic  tenesmus  and  pain  in  the 
ovarian  regions,  presumably  in  the  stumps  left  after  the  removal  of 
the  ovaries. 

The  next  symptoms  in  the  history  are  derangement  of  the  circu- 
lation, chiefly  vaso-motor,  due  to  deranged  innervation  ;  irregular 

*  Medical  Press,  November  8,  1893. 


444  DISEASES  OF  WOMEN. 

heart  action  ;  flashes  of  heat,  and  cold  hands  and  feet ;  cold  per- 
spiration followed  by  hot,  dry,  feverish  skin ;  numbness  of  the 
extremities,  most  frequently  of  the  left  arm ;  creeping,  crawling 
feelings  in  the  skin,  and  burning  spots  here  and  there.  Nutrition 
is  generally  impaired,  and  nervous  indigestion  is  present  in  all  cases 
as  a  rule.  Assimilation  is  defective,  as  the  loss  of  flesh  and  softened 
state  of  the  muscles  indicate.  The  skin  shows  malnutrition  in  being 
either  dry  and  hot  or  cold  and  clammy.  These  indications  are  all 
more  marked  at  the  time  when  the  patient  should  menstruate.  These 
periodical  exacerbations  are  most  distinct  at  the  flrst.  As  time  goes 
on  the  patients  adapt  themselves  to  the  new  order  of  things  gradu- 
ally. If  properly  managed,  recovery  may  take  place  in  time,  but  if 
left  without  care  they  become  chronic  invalids  or  insane.  Artificial 
menopause  is  more  often  followed  by  insanity  than  the  normal 
climacteric. 

The  effect  upon  sexual  instincts  of  removal  of  the  ovaries  in 
adolescence  has  been  discussed  long  and  laboriously  in  the  past 
years,  but  nothing  new  has  been  advanced.  Repetition  of  the  two 
opposite,  old,  and  rather  ridiculous  ideas — one,  that  the  removal  of 
the  ovaries  unsexes  women,  and  the  other,  that  it  does  not  affect 
them  at  all  in  this  respect — is  about  all  that  has  been  heard  on  this 
subject  during  the  last  eighteen  or  twenty  years.  The  fact  is,  that 
it  does  not  unsex  women,  but  in  time  impairs  sexual  characteristics, 
and  they  are,  as  a  rule,  finally  lost.  The  passing  away  of  the  sexual 
appetence  and  the  consciousness  of  being  positively  sterile  often 
have  a  most  disastrous  effect  upon  the  mind,  and  frequently  lead  to 
insanity.  I  will  refer  to  this  again  in  treating  of  insanity  among 
women. 

Treatment. — The  first  indication  is  to  quiet  the  mental  disturb- 
ance. Much  can  be  done  to  relieve  the  patient's  depression  by 
giving  hope  of  recovery.  Sedatives  are  required  to  give  sleep,  and 
nerve  tonics,  such  as  are  suitable  in  melancholia,  are  called  for ; 
camphor,  lupulin,  and  in  some  cases  small  doses  of  opium,  give 
relief.  The  opium  should  be  given  with  care,  and  without  the 
patient  knowing  what  she  is  taking.  Lately  I  have  used  codeine 
with  better  effect  than  opium  gives.  The  deranged  circulation  is 
best  managed  with  a  combination  of  digitalis,  strychnine,  and  bella- 
donna. Occasional  attacks  of  palpitation  of  the  heart — pain  in  the 
cardiac  region  with  difficult  respiration — are  relieved  with  nitro- 
glycerin, strophanthus,  and  digitalis.  Indigestion  is  generally  of 
the  nervous  type,  and  is  controlled  by  gastric  sedatives  such  as  bis- 
muth and  oxalate  of  cerium,  or  subgallate  of  bismuth.     The  spinal 


THE   MENOPAUSE.  445 

symptoms  are,  I  presume,  due  to  a  hypersemic  or  anabolic  state, 
hence  the  irritability,  nervous  twitchings,  and  neuralgic  pains. 
"When  these  are  annoying,  relief  is  obtained  by  dry  cupping,  alter- 
nating with  hot  and  cold  douches,  or  sprayings,  hot  and  cold, 
applied  in  rapid  succession  to  the  lumbar  regions.  Time  is  the 
great  factor  in  restoring  the  equilibrium,  and  the  main  object  is 
to  relieve  and  sustain  the  patient  until  the  new  order  of  things  is 
established. 

Enforced  Menopause  from  disease,  injury,  or  removal  of  the 
uterus,  while  the  ovaries  are  left,  causes  a  general  derangement 
which  may  be  termed  an  exaggerated  menstrual  molimen.  The 
nutritive  preparations  for  menstruation  go  on,  and  when  the  elimi- 
native  function  is  not  performed  there  is  a  temporary  plethora. 
The  patient  complains  of  fullness  of  the  head,  flushed  face,  very 
often  headache,  and  oppression  which  is  felt  as  weakness  and  indis- 
position to  engage  in  mental  or  phj'sical  exercise.  The  nervous 
systemic  disturbance  is  manifested  by  drowsiness,  low-spiritedness, 
and  inability  to  think  clearly  and  quickly.  Those  of  a  nervous 
temperament  are  irritable,  fretful,  and,  although  sleepy  at  times 
during  the  day,  often  have  sleepless  nights. 

Treatment. — The  old  practitioners  employed  bloodletting,  and 
with  decided  benefit.  In  strong  women  it  might  be  practiced  with 
advantage  at  the  present  time,  but  it  should  not  be  continued  at 
each  recurring  menstrual  period,  as  the  habit  of  requiring  bleeding  is 
easily  established.  Depletion  by  other  means,  like  saline  cathartics, 
for  example,  gives  much  relief,  and  mercurials  are  of  great  value  when 
the  liver  and  kidneys  are  inactive.  Small  repeated  doses  of  mild 
chloride  of  mercury,  followed  by  a  saline,  or  natural  cathartic  waters, 
act  well,  and  Turkish  baths  and  muscular  exercise  aid  in  some  cases. 
The  headache  often  complained  of  as  a  painful  fullness  is  best  re- 
lieved by  bromide  of  soda  with  antipyrine  or  monobromide  of 
camphor.  Piperazine  is  the  best  solvent,  and  gives  great  relief  in 
the  uric-acid  saturation  which  is  often  present  and  causes  neuralgic, 
rheumatic,  and  gouty  symptoms.  The  diet  should  consist  of  milk, 
eggs,  vegetables,  and  fruit,  with  very  little  animal  food.  The  quan- 
tity of  food  should  be  limited  ;  underfeeding  rather  than  full  diet 
should  be  the  rule.  Some  women  have  a  craving  for  alcoholic 
drinks,  but  these  should  be  prohibited. 

The  indications  for  treatment  are  based  upon  the  fact  that  the 
function  of  the  sexual  organs  is  suspended  before  the  nervous  and 
nutritive  systems  have  been  prepai-ed  for  the  change  in  the  economy. 
The  nutritive  activities  are  out  of  proportion  to  the  demand,  and 


446  DISEASES  OF  WOMEN. 

therefore  the  supply  should  be  diminished.  If  it  is  not,  the  nutri- 
tive processes  become  deranged.  These  derangements  should  be 
treated  in  the  usual  way. 

The  disorders  of  the  nervous  system  arising  from  enforced  meno- 
pause from  the  causes  now  being  considered  are  also  twofold.  There 
is  in  one  class  an  exalted  nerve  force,  which,  no  longer  finding  an 
outlet  through  the  demands  of  the  sexual  system,  gives  rise  to  nerv- 
ous derangements  which  should  be  relieved  by  sedatives,  and  diver- 
sion of  the  nerve  forces  in  some  other  direction  by  mental  occupa- 
tion. Women  who  have  given  their  best  mental  energies  to  the 
exercise  of  the  sexual  system  suffer  most  from  premature  meno- 
pause. 

There  is  another  class  who  suffer  from  nervous  exhaustion  or 
debility.  They  manifest  nervous  excitability  with  loss  of  power ; 
they  are  called  nervous  patients.  All  such  require  rest,  tonics,  and 
good  nourishment.  Whenever  the  nervous  system  is  specially  dis- 
turbed at  the  menopause  the  greatest  care  is  required  to  keep  its 
'disorders  from  going  from  bad  to  worse.  There  is  a  tendency  to 
develop  diseases  of  the  nervous  system  in  many  forms,  and  if 
there  is  any  inherited  tendency  to  insanity  it  will  be  brought  out 
under  these  circumstances. 

Delayed  Menopause. — The  menstrual  function  is  sometimes  con- 
tinued to  an  advanced  age  in  strong,  healthy  women,  but  so  long  as 
the  function  is  normal  there  is  no  reason  for  being  alarmed.  It  is 
only  when  the  menses  continue  beyond  the  usual  time  for  the  meno- 
pause and  there  is  some  derangement  in  that  function,  or  the  gen- 
eral health  is  impaired,  that  attention  should  be  given  to  the  subject. 
Efforts  should  be  made  to  discover  the  local  or  general  conditions 
which  cause  these  derangements.  When  the  flow  is  profuse  and 
irregular  in  recurrence,  there  is  usually  some  local  cause  for  it  that 
can  be  easily  discovered. 

It  may  be  said,  in  brief,  that  any  neoplasm,  subinvolution,  or  old 
injuries  of  the  uterus  may  keep  up  menstruation  beyond  its  normal 
limit.  Scar  tissue  in  the  cervix  uteri,  either  from  injuries  or  from 
the  use  of  caustics,  apparently  prevents  the  final  atrophy  of  the 
uterus  by  keeping  up  a  continuous  irritation.  This  is  the  only  way 
that  one  can  account  for  the  relief  obtained  in  such  cases  by  dilat- 
ing the  canal  of  the  cervix.  A  number  of  cases  of  recovery  from 
painful  menstruation  and  delayed  menopause  have  been  reported 
cured  by  this  form  of  treatment.  Uterine  fibroids  and  subinvolu- 
tion, as  well  as  scar  tissue  of  the  uterus,  all  belong  to  the  domain  of 
surgery,  and  are  only  referred  to  here  as  belonging  to  causation. 


THE  MENOPAUSE.  447 

Delayed  menopause  is  also  caused  by  certain  constitutional 
conditions,  such  as  hepatic,  cardiac,  and  renal  disease,  and  also 
certain  blood  states  which,  if  they  do  not  favor  a  continuation  of 
menstruation  long  after  the  time  for  change  of  life,  certainly  cause 
menorrhagia  about  the  time  for  the  menopause.  Menorrhagia  and 
delayed  menopause  are  not  infrequent  in  cases  of  mitral  insuffi- 
ciency. The  effect  of  this  cardiac  lesion  upon  tlie  circulation  is  to 
keep  up  a  continued  hyperaBmia  of  the  pelvic  organs,  and  this  often 
causes  women  to  go  on  menstruating  when  they  are  old  enough  to 
have  the  menopause,  and  when  they  can  ill  afford  to  keep  up  that 
function.  The  diagnosis  is  easily  made  by  the  physician  who  makes 
his  examination  sufficiently  thorough. 

The  treatment  consists  in  trying  to  improve  the  circulation.  At 
the  menstrual  period  the  patient  should  be  kept  in  the  recumbent 
position  as  long  as  it  can  be  borne  with  comfort.  She  should  rest, 
not  necessarily  upon  her  back,  but  on  either  side  that  is  most  com- 
fortable. Massage  and  hot-water  douches,  which  I  do  not  hesitate 
to  recommend  if  the  flow  is  excessive,  will  sometimes  control  this 
condition.  Digitalis  and  aromatic  sulphuric  acid  in  medium  doses 
will  frequently  give  great  relief,  and  they  are  far  better  borne 
than  hydrastis  canadensis  or  ergot  in  those  cases  of  cardiac  disease. 

Hepatic  disease,  such  as  the  engorgement  and  enlargement  oc- 
curring in  chronic  malarial  poisoning,  not  rarely  causes  menorrhagia 
in  young  women,  and  is  very  apt  to  delay  the  menopause.  This  no 
doubt  is  also  due  to  the  deranged  portal  circulation,  which  keeps  up 
the  pelvic  engorgement.  The  treatment,  of  course,  should  be  such 
as  the  physician  employs  in  chronic  malaria.  It  will  suffice  to  add 
here  that,  in  addition  to  the  use  of  the  alkaloids  of  cinchona  bark 
and  arsenic,  I  have  found  the  most  marked  benefit  from  the  use  of 
iodine.  I  give  five  drops  of  the  tincture  in  water,  with  enough  of 
the  iodide  of  soda  to  make  a  clear  solution.  The  formula  is  :  Tinc- 
ture of  iodine,  two  drachms ;  iodide  of  sodium,  half  a  drachm ; 
simple  sirup,  one  ounce  ;  water,  two  ounces.  Dose,  one  drachm 
after  meals,  well  diluted.  To  this  I  very  often  add  two  or  three 
drops  of  Fowler's  solution.  Of  course,  attention  to  the  bowels  and 
general  nutrition  should  be  fully  given. 

The  premature  menopause  has  been  referred  to  as  arising  from 
certain  constitutional  affections,  notably  tuberculosis,  and  so  on. 
Nothing  need  here  be  said  about  this,  as  suppression  of  menstrua- 
tion is  a  conservative  matter  and  requires  no  direct  attention.  It 
may  be  well  to  add  also  that  in  case  the  physician  can  not  find  any 
disturbance  of  the  nutritive  or  nervous  system  to  account  for  the 


448  DISEASES  OP  WOMEN. 

delayed  menopause,  it  is  evident  that  the  cause  is  local,  and  such 
patients,  of  course,  should  be  relegated  to  the  domain  of  surgery. 

ILLUSTRATIVE    CASES. 

A  Case  illustrating  the  Normal  Menopause. — A  lady  who  had  a 
very  good  constitution,  and,  with  the  exception  of  having  had  some 
acute  diseases  in  early  life,  had  enjoyed  uniform  good  health.  She 
had  borne  five  children,  and  after  the  birth  of  the  last  one  she  men- 
struated regularly  and  perfectly.  Wlien  she  was  forty-six  years 
old  the  menstrual  flow  began  to  diminish  in  quantity  and  duration, 
varying  a  little  in  this  respect  from  time  to  time.  In  six  months 
from  the  time  that  the  change  began,  the  duration  of  the  flow  was 
reduced  from  five  days  to  two.  She  then  missed  two  periods,  and 
then  the  flow  returned  and  lasted  three  days,  and  was  a  little  freer. 
Then  she  went  for  four  months,  when  there  was  a  slight  show  for 
part  of  a  day,  and  that  was  the  end. 

During  the  time  when  the  gradual  diminution  of  the  flow  was 
taking  place  she  became  somewhat  languid,  and  indisposed  to  her 
usual  mental  and  physical  activity.  Her  appetite  was  not  quite  as 
good  as  formerly.  While  languid  when  undisturbed,  she  was  easily 
roused  by  any  excitement.  Her  face  would  become  flushed,  her 
hands  and  feet  clammy,  and  she  was  nervous  and  irritable.  When 
these  feelings  passed  away  she  felt  annoyed  to  think  that  she  could 
not  control  herself  as  in  times  past,  and  would  become  a  little  de- 
spondent. All  these  symptoms  were  more  pronounced  at  the  men- 
strual periods.  When  suffering  most  she  felt  that  if  she  could  have 
a  free  menstrual  flow  it  would  relieve  her.  These  feelings  continued 
to  annoy  her  until  the  flow  ceased  entirely,  and  for  about  nine 
months  afterward,  but  they  diminished  in  severity,  and  finally  left 
her  altogether. 

After  the  cessation  of  the  flow  she  gained  considerable  flesh,  and 
her  former  mental  and  physical  activity  returned,  and  her  health  has 
been  excellent  ever  since. 

When  the  diminution  in  the  flow  began  and  her  peculiar  symp- 
toms came  on,  she  consulted  me  about  her  condition.  When  told 
that  all  could  be  attributed  to  the  change  of  life,  slie  pleasantly  ac- 
cepted the  situation,  and  made  no  change  in  her  mode  of  life,  nor 
(lid  she  take  any  medicine.  This  enabled  me  to  ol)tain  the  history 
of  the  case  uimiodified  by  treatment. 

Premature  Menopause  caused  by  Deranged  Innervation. — The  pa- 
tient was  one  having  a  good  organization,  but  a  very  marked  nervous 
temperament.     She  had  three  children,  the  youngest  of  whom  was 


i 


THE  MENOPAUSE.  449 

five  years  of  age  when  I  fii'st  saw  her.  She  was  then  thirty-six  years 
old.  Three  years  before  our  first  consultation  she  had  many  exciting 
cares  thrust  upon  her,  which  affected  her  nervous  system  very  injuri- 
ously. Though  possessed  of  means  sufficient  to  secure  every  luxury 
of  life,  her  cares  depressed  her  greatly,  and  exhausted  her  nervous 
system.  Her  nutrition  was  impaired  to  some  extent,  but  still  she 
had  the  appearance  of  one  in  fair  health,  although  she  was  restless, 
sleepless,  had  headache  very  often,  and  suffered  from  wandering 
neuralgic  pains. 

Her  sufferings  in  this  way  had  continued  for  about  one  year, 
during  which  time  the  menstrual  flow  was  at  times  scanty,  and  less 
in  duration  than  normal.  Then  the  menses  stopped  altogether  for 
six  months,  then  returned  for  several  months,  though  scantily,  then 
ceased  for  two  months,  returned  once,  and  then  again  in  four  months, 
and  then  stopped  entirely. 

Five  months  after  the  last  menstruation  was  the  time  that  I  first 
saw  her.  She  consulted  me  because  she  fancied  that  if  her  menses 
would  return  her  health  would  improve.  To  describe  her  symptoms 
would  be  tedious  and  unprofitable ;  suffice  it  to  say  that  she  presented 
typical  neurasthenia.  There  was  no  organic  disease  noticeable  out- 
side of  the  nervous  system.  Being  fully  satisfied  that  if  the  men- 
strual function  could  ever  be  restored  it  must  be  accomplished  by 
restoring  the  nervous  system  first,  the  treatment  was  directed  to  that 
object.  Sleep  at  night  was  obtained  by  giving  thirty  grains  of  bro- 
mide of  sodium  late  in  the  afternoon,  and  half  an  ounce  of  whisky  at 
bedtime.  Aconitia,  one  two-hundredth  of  a  grain,  relieved  her  at- 
tacks of  neuralgia.  Massage  and  general  faradization  were  employed 
daily,  and  tonics  were  given,  consisting  first  of  valerianate  of  zinc, 
then  pyrophosphate  of  iron  and  arsenic,  and  then  iodide  of  iron. 

Citrate  of  iron  and  quinine  was  also  given  at  times.  The  form 
of  tonic  was  changed  whenever  she  became  used  to  that  which  she 
was  taking,  and  the  most  appropriate  diet  was  given.  Her  general 
health  improved  gradually,  and  in  the  summer  she  was  able  to  rest 
and  enjoy  life  in  the  country  by  the  sea.  Sea  bathing  was  also  tried 
after  a  time  with  benefit.  About  one  year  of  this  treatment  restored 
her  health,  but  the  menses  did  not  return.  In  fact,  the  restoration 
of  that  function  was  despaired  of  after  three  months'  treatment, 
when,  on  examination,  it  was  found  that  the  organs  of  generation 
had  undergone  complete  involution. 

The  Menopause  delayed  by  Fungosities  of  the  Endometrium. — This 
patient  was  married,  and  the  mother  of  five  children.  After  the 
birth  of  her  last  child  she  suffered  from  uterine  leucorrhoea,  proba- 
30 


450  DISEASES  OF  WOMEN. 

bly  caused  by  endometritis.  She  had  fair  health  in  spite  of  that, 
and  menstruated  regularly  until  she  was  forty-six  years  old,  and  then 
the  menstrual  ilow  became  more  profuse.  This  continued  intermit- 
tently for  nearly  one  year,  when  the  menses  came  more  frequently, 
lasted  longer,  and  the  flow  was  quite  profuse.  Her  health  failed 
gradually ;  she  became  ansemic,  weak,  low-spirited,  and  nervous. 
Tliough  her  flesh  remained  (she  was  rather  stout),  her  strength  was 
greatly  reduced.  Her  family  physician  gave  her  the  usual  remedies 
— lead  and  opium,  ergot,  cannabis  Indica,  and  aromatic  sulphuric 
acid — in  the  hope  of  controlling  the  flow,  but  without  effect. 

Finally  she  consented,  with  some  reluctance,  to  an  examination, 
when  a  large  number  of  polypoid  growths  were  found  in  the  cavity 
of  the  uterus.  These  were  removed  with  the  curette,  and  the  flow- 
ing stopped  for  six  weeks  ;  it  then  returned  for  a  few  days,  but  was 
not  very  free.  There  was  a  return  of  the  menstrual  flow  in  two 
months,  very  scanty,  and  another  in  three  months,  and  that  was  the 
end  of  it.  She  was  then  forty-eight  years  old.  After  the  removal 
of  the  fungous  growths  with  the  curette,  her  health  improved  under 
tonic  treatment,  and  when  last  seen,  at  forty-nine  years  of  age,  she 
was  quite  well. 

Excrementitious  Plethora,  Oppression,  and  Derangement  of  the 
Nervous  System  from  the  Menopause. — A  strong-looking  German 
lady  gave  me  the  following  history :  She  was  married  and  in  quite 
comfortable  circumstances.  She  had  six  children,  the  youngest 
being  eleven  years  old.  From  the  time  of  her  last  confinement 
her  health  had  been  good,  and  she  menstruated  normally  until  she 
was  over  forty-six  years  of  age.  Her  menses  came  then  at  the 
proper  time,  but  lasted  two  weeks,  and  the  flow  was  too  free.  After 
a  lapse  of  three  months  the  menses  came  again  in  a  diminished  de- 
gree, and  again  in  two  months  scantily.  From  the  time  of  her 
free  menstruation,  when  she  was  about  forty-six  years  old,  her 
health  failed  gradually.  She  had  always  been  a  generous  liver,  and 
continued  to  take  her  nourishment  well,  but  she  became  languid, 
indisposed  to  exertion  of  any  kind,  had  headaches,  was  drowsy  and 
sleepy  all  the  time,  but  often  had  restless  nights.  Her  mind  was 
disturbed,  so  that  she  was  depressed  in  spirits,  quite  fretful,  did  and 
said  "  queer  things "  which  alarmed  her  family,  and  her  memory 
was  less  reliable  than  formerly.  She  had  little  interest  in  her  for- 
mer duties  and  amusements,  but  occupied  her  time  mostly  in  think- 
ing and  talking  about  her  feelings.  There  were  flushings  of  the 
face  at  times,  which  she  described  as  rushing  of  blood  to  the  head, 
which  she  fancied  might  kill  her.     There  were  profuse  but  brief 


THE  MENOPAUSE.  45 1 

paroxysms  of  perspiration,  which  came  at  times  without  any  phys- 
ical exertion.  She  was  qnite  fleshy,  and,  excepting  an  anxious  ex- 
pression of  the  face,  had  the  appearance  of'  good  health.  The 
tongue  was  coated,  the  bowels  constipated,  the  urine  was  loaded 
with  phosphates ;  the  pulse  full,  but  slow,  and  at  times  irregular ; 
the  appetite  was  not  good,  but  she  took  food  in  abundance,  and 
drank  wine  and  beer  in  the  hope  of  getting  strength.  She  suffered 
from  labored  digestion  and  flatulence,  and  a  sense  of  fullness  in 
the  region  of  the  stomach.  The  sexual  organs  had  undergone  com- 
plete involution,  although  the  vagina  was  relaxed  and  showed  some 
venous  congestion. 

The  treatment  was  first  ten  grains  of  blue-mass,  three  grains  of 
calomel,  and  one  grain  of  ipecac,  given  at  bed-time,  followed  in  the 
morning  with  a  dose  of  sulphate  of  magnesia.  This  was  repeated 
twice,  at  intervals  of  five  days,  and  after  that  the  following  mixture 
was  given  :  Bromide  of  sodium,  half  an  ounce ;  salicylate  of  sodium, 
two  drachms  ;  wine  of  colchicum  seeds,  two  drachms ;  sirup  and 
water  enough  to  make  three  ounces,  and  a  teaspoonful  to  be  taken 
before  meals.  She  improved  very  much  on  this  treatment,  and 
the  mixture  was  continued  for  about  six  weeks.  After  the  effects 
of  the  mercurial  cathartic  had  passed  off  she  became  constipated, 
and  the  following  pill  was  given  at  bed-time :  Sulphate  of  quinine, 
one  grain ;  extract  of  belladonna,  one  eighth  of  a  grain ;  and  rhu- 
barb, two  grains.  When  this  was  not  sufficient  to  move  the 
bowels  freely,  a  glass  of  Congress  water  was  given  an  hour  before 
breakfast.  Wine  and  beer  were  gradually  given  up,  and  her  diet 
simplified  and  reduced  in  quantity.  Exercise  in  the  open  air  was 
prescribed,  and  light,  agreeable  mental  occupation.  The  progress 
of  the  case  was  quite  satisfactory  for  about  two  months,  then  there 
was  a  standstill  for  a  time.  The  medicine  was  then  changed  to  a 
mixture  of  hydrochloric  acid,  one  and  a  half  drachm  ;  tincture  nux 
vomica,  one  and  a  half  drachm  ;  tincture  of  cannabis  Indica,  two 
drachms ;  tincture  of  cardamom,  one  ounce  ;  and  simple  sirup,  two 
ounces  ;  one  drachm,  before  meals,  in  water.  The  pill  at  bedtime  was 
continued.  This  last  prescription  was  given  for  about  two  months 
with  an  interval  of  three  days  after  each  bottle,  when  she  took  the 
pill  only,  at  night.  From  this  time  onward  the  progress  of  the  case 
was  steady  until  she  finally  recovered  her  former  good  health. 

Such  a  case  as  this  is  infrequently  seen  in  practice.  The  causes 
being  conditions  of  life  favoring  derangement  of  nutrition  and  slug- 
gish disintegration,  aggravated  greatly  by  the  rather  abrupt  cessation 
of  the  menses. 


452  DISEASES  OF  WOMEN. 

Impaired  Digestion  and  Assimilation  arising  from  the  Cessation  of 
Menstruation. — This  lady  was  married  and  the  mother  of  a  family, 
of  spare  habit  and  a  nervous  temperament,  but  her  health  had  been 
good  in  the  past.  When  she  was  forty  years  of  age  her  menstrual 
liow  diminished  in  quantity  and  duration,  and  simultaneously  her 
appetite  failed,  and  she  lost  flesh  and  strength. 

Always  an  active  person,  she  now  became  restless,  nervous,  and 
irritable.  Her  tongue  was  clean,  but  of  a  deeper  color  than  nor- 
mal, showing  that  rapid  exfoliation  of  the  epithelium  was  going 
on.  The  bowels  were  constipated  ;  the  urine  was  abundant  and  of 
light  color  usually.  Her  skin  was  slightly  bronzed  and  usually  dry, 
although  she  had  occasional  outbursts  of  free  perspiration.  Her 
pulse  was  weak,  and  at  times  irregular.  Her  head  ached  quite  often, 
and  she  had  wandering  pains  about  the  chest  and  abdomen.  Her 
greatest  trouble  was  a  feeling  of  distress  in  the  stomach  after  eating. 
Eight  months  from  the  time  that  the  menstrual  flow  began  to  de- 
cline it  stopped  altogether,  and  two  months  afterward  I  first  saw  her. 

As  the  physical  condition  of  this  patient  was  almost  exactly  the 
opposite  of  the  preceding  case,  the  treatment  was  necessarily  very 
diiierent.  She  was  directed  to  take  nutritious  food  in  small  quan- 
tity, six  times  a  day ;  to  rest  as  much  as  possible,  and  have  massage 
at  night,  which  gave  better  sleep. 

At  first  she  was  given  five  grains  of  oxalate  of  cerium  half  an 
hour  before  meals,  and  a  teaspoonful  after  meals,  in  warm  water, 
of  a  mixture  of  lactic  acid,  tincture  of  columbo,  and  pepsin  wine, 
and  she  improved  so  far  as  to  take  food  and  digest  it  with  less 
trouble,  but  her  strength  did  not  return  as  fast  as  I  desired.  She 
was  also  constipated.  A  tonic  laxative  pill  was  then  given  before 
meals,  consisting  of  quinine,  belladonna,  and  compound  extract  of 
colocynth  ;  and  after  meals  she  was  given  a  teaspoonful  of  whisky 
with  four  drops  of  tincture  of  nux  vomica  and  four  grains  of  animal 
charcoal.  This  appeared  to  help  her,  and  this  course  of  tonic  treat- 
ment was  continued  very  faithfully  for  three  months,  when  she  con- 
sidered herself  sufficiently  well  without  further  treatment. 

Two  years  afterward  she  was  found  to  be  in  good  health. 

Circumscribed  Inflammation  of  the  Vagina  and  Cervix  TJteri,  partly 
due  to  the  Menopause. — The  patient  was  first  seen  when  she  was 
forty-eight  years  old.  The  menses  had  stopped  one  year  and  two 
months  l)efore.  Her  health  was  fairly  good  and  alwaj'S  had  been, 
but  for  some  time  before  the  menopause,  and  all  the  time  after,  she 
had  been  distressed  by  a  discharge  from  the  vagina  of  sero-purulent 
but  rather  tenacious  material,  which  caused  some  external  irritation. 


THE   MENOPAUSE.  453 

There  was  heat  and  burning  in  tlie  pelvis,  which  became  more 
marked  on  walking.  She  had  put  np  with  her  troubles  so  long, 
believing  that  it  was  due  to  change  of  life  and  would  pass  off  in 
time.  In  fact,  she  had  been  told  this  by  her  physician.  But,  in- 
stead of  disappearing,  she  found  that  the  trouble  increased,  if  indeed 
it  changed  at  all.  Her  general  health  was  below  par  considerably, 
but  there  was  no  organic  disease  of  the  organs  of  nutrition,  and  yet 
ultimate  nutrition  was  a  little  sluggish. 

The  sexual  organs  had  undergone  final  involution  ;  the  uterus 
was  small,  but  the  os  externum  was  open,  and  coming  from  the 
canal  was  a  tenacious,  darkish-colored  discharge,  not  unlike  the  leu- 
corrhcea  found  in  young  subjects,  and  heretofore  described  under 
the  head  of  "  Cervical  Endometritis  in  the  Imperfectly  Developed 
Uterus." 

The  mucous  membrane  about  the  external  os  was  eroded  in 
patches,  and  on  the  anterior  lip  of  the  cervix  there  were  some 
granular  spots  that  looked  as  if  they  were  the  products  of  epithelial 
hyperplasia.  The  aj)pearance  of  the  vagina  was  peculiar.  In  place 
of  the  general  congestion  of  a  well-marked  vaginitis,  the  mucous 
membrane  was  studded  with  small  red  points  or  patches,  while  the 
intervening  portions  of  the  membrane  were  pale.  The  surface  of 
the  membrane  was  covered  with  a  sero-purulent  discharge ;  at  the 
vulva  there  were  several  patches  of  congestion  larger  than  those 
higher  up  in  the  vagina.  Some  of  these  were  of  a  deep-red  and 
slightly  bluish  color. 

The  thought  came  to  me  that  this  might  be  malignant  disease  of 
the  cervix  just  beginning,  but  this  was  put  aside,  because  of  the 
duration  of  the  trouble  and  the  fact  that  I  have  several  times  seen 
this  condition  after  the  menopause. 

I  have  also  frequently  seen  the  same  conditions  in  young  insane 
women  who  had  amenorrhoea.  These  facts  led  me  to  suppose  that 
the  inflammatory  action  was  due  to  impaired  nutrition  which  is  pres- 
ent at  the  involution  of  the  sexual  organs.  This  low  grade  of  in- 
flammatory action  is  no  doubt  more  likely  to  occur  in  those  who 
have  had  some  ordinary  cervical  endometritis  and  vaginitis  before 
the  menopause.  The  circumscribed  red  spots  looked  to  me  like  a 
few  live  coals  here  and  there  in  the  ashes  left  after  the  fires  of  func- 
tional life  and  inflammation  had  subsided. 

The  treatment  consisted  of  general  tonics  and  local  astringents ; 
citrate  of  iron  and  quinine  was  given  internally,  and  a  teaspoonful 
of  sulphate  of  zinc  in  a  quart  of  water  for  a  vaginal  douche. 

The  parts  about  the  os  externum  were  touched  once  with  a  fifty- 


454  DISEASES  OF  WOMEN. 

per-cent  solution  of  chloride  of  zinc.  The  sulphate-of-zinc  injec- 
tions did  very  well  for  a  time,  but  the  progress  was  favored  by  an 
occasional  application  of  glycerin  and  tannic  acid. 

The  local  improvement  did  not  surpass  the  general  regaining  of 
strength,  but  kept  pace  with  it.  The  recovery  was  permanent  and 
perfect. 

Pelvic  pains  of  a  neuralgic  character  are  common  about  the 
change  of  life,  and  are  often  due  to  it.  The  following  two  cases 
from  Tilt  will  illustrate  this  form  of  trouble  : 

Ovario-Uterine  Neuralgia. — Miss  X.  was  forty-seven  when  she 
first  consulted  me.  She  is  small,  but  well-proportioned.  Has  been 
highly  nervous  all  her  life.  Menstruation  was  irregular,  and  there 
were  muco-purulent  discharge,  vaginitis,  and  decided  ulceration  of 
the  cervix,  and  a  most  irksome  sensation  of  heat  and  irritation  in  the 
passages.  I  cured  the  vaginitis  and  ulceration  by  surgical  measures, 
without  relieving  the  vaginal  heat  and  pruritus,  so  I  sent  the  patient 
out  of  town.  When  she  returned,  after  many  months,  the  pruritus 
was  as  bad  as  ever,  and  would  come  on  after  any  excitement  or 
fatigue,  or  standing  about,  and  would  be  relieved  by  resting  with 
the  feet  higher  than  the  pelvis.  This  vulvo- vaginal  irritation  would 
sometimes  disappear  on  the  coming  on  of  a  similar  pruritus  on  the 
palms  of  the  hands  and  on  the  soles  of  the  feet,  showing  that  how- 
ever much  the  chief  seat  of  neuralgia  might  be  in  the  womb  or 
vagina,  the  ultimate  nervous  expansions  in  other  parts  of  the  body 
might  similarly  suffer.  When  this  irritation  affects  the  feet  and 
hands  there  is  nothing  to  be  seen  there,  and  she  refrains  from 
scratching  them  because  it  would  prolong  the  irritation  for  hours. 
As  might  have  been  predicted,  the  symptoms  were  worse  at  night, 
and  led  to  great  exhaustion  and  despondency.  I  have  watched  this 
state  of  things  for  twenty  years,  and  at  times  could  give  no  relief. 
She  was  always  better  for  plenty  of  food  and  wine,  and  for  such 
small  quantities  of  citrate  of  iron  and  quinine  as  she  could  bear.  I 
tried  all  sorts  of  injections;  tar-water  did  most  good,  but  it  has 
been  repeatedly  advisable  to  discontinue  all  kinds  of  injection,  for 
they  seemed  to  do  more  harm  than  good.  I  syringed  the  vagina 
with  a  solution  of  nitrate  of  silver  and  touched  the  passage  M'ith  the 
solid  caustic,  with  questionable  benefit.  A  rectal  suppository  con- 
taining a  grain  of  opium  and  one  of  extract  of  belladonna  often 
gave  tem])orary  relief,  but  this  remedy  could  not  be  relied  on.  By 
the  sacrifice  of  her  own  health  many  a  daughter  has  well  repaid  the 
gift  of  life ;  and  when  my  patient  lost  her  mother,  who  had  been 
long  a  cripple,  requiring  anxious  and  fatiguing  nursing,  she  went 


THE  MENOPAUSE.  455 

out  of  town  and  got  fat,  and  now  suffers  much  less,  only  having  a 
slight  return  of  the  old  symptoms  when  she  gets  weaker  and  more 
nervous. 

Ovario-Uterine  Neuralgia. — A  very  strongly  constituted  lady,  aged 
forty-seven,  is  said  to  have  had  some  acute  uterine  disease  twenty 
years  ago,  while  residing  in  France,  when  forty  leeches  were  ap- 
plied above  the  pubis.  With  the  exception  of  not  being  able  to  re- 
tain the  urine  so  well  as  previously  to  this  attack,  health  remained 
so  good  that  every  year  she  was  able  to  take  long  pedestrian  excur- 
sions with  her  husband.  She  never  conceived,  and  menstruation 
ceased  suddenly  at  forty-four  ;  in  the  following  months  the  nose 
bled  very  frequently,  and  the  bowels  became  constipated  ;  for  which 
she  went  to  Homburg  and  was  restored  to  health.  On  returning  to 
town,  in  December,  1868,  she  took  very  cold  enemata  for  constipa- 
tion, which  was  so  great  that  a  wineglass  of  Friedrichshall  water, 
taken  every  hour,  failed  to  produce  watery  motions,  and  only  irri- 
tated the  bladder,  apparently  causing  the  strange  abdominal  sensa- 
tions which  have  lasted  ever  since.  The  patient  feels  as  if  there 
were  a  heavy  body  in  the  pelvis  bearing  down  upon  the  rectum, 
with  a  burning  sensation,  referred  sometimes  to  that  organ,  some- 
times to  the  vagina,  or  to  the  bladder.  When  in  bed  and  lying  down, 
with  the  feet  up,  she  feels  comfortable ;  by  the  time  she  has  half 
done  dressing  the  burning  sensation  begins,  and  lasts  until  the  bowels 
have  been  moved  ;  soon  after  this  the  burning  comes  back  ;  it  is  ag- 
gravated by  standing  or  sitting,  by  indigestion,  flatulence,  constipa- 
tion, and  repletion  of  the  bladder ;  also  by  worry  and  bad  news. 
The  sensation  is  relieved  by  moderate  walking,  by  lying  down,  and 
by  regularity  of  the  bowels.  Homburg  was  again  tried  ;  it  did  good, 
but  on  her  return  the  lady  was  as  bad  as  before,  and  consulted  sev- 
eral doctors.  One  attributed  the  sufferings  to  stricture  of  the  rec- 
tum, another  to  irritation  of  the  bladder,  a  third  to  displacement 
of  the  womb.  The  following  summer  Homburg  was  tried  for  a 
third  time,  but  the  waters  were  soon  left  off,  for  they  aggravated  all 
the  symptoms,  and  after  the  patient's  return  to  town  Dr.  Beale  sent 
her  to  me.  In  addition  to  the  pelvic  symptoms  already  described  a 
strong-minded,  sharp,  matter-of-fact  woman  was  in  a  state  of  mental 
confusion  ;  her  brain  felt  muddled,  and  she  would  sit  for  hours  doz- 
ing or  doing  nothing ;  despondency  being  doubtless  increased  by 
finding  herself  helpless  as  a  child,  after  having  passed  all  her  life 
in  doing  everybody  else's  business  as  well  as  her  own.  She  forgot 
where  she  put  things ;  once  thought  she  had  taken  out  a  large  sum 
of  money  in  her  purse,  and  that  she  had  lost  it,  whereas  a  month 


4,56  DISEASES  OF  WOMEN. 

afterward  she  found  it  in  some  out-of-the-way  place.  On  examin- 
ing, I  found  the  rectum  perfectly  healthy,  notwithstanding  the  pain 
and  stricture  ascribed  to  it.  I  was  given  to  understand  that  marriage 
had  never  been  concluded,  and  the  vagina  was  so  narrow  that  1  could 
with  difficulty  introduce  part  of  my  index  finger ;  so  I  ordered  lin- 
seed tea  and  laudanum  injections,  three  times  a  day,  and  henbane 
internally.  A  few  days  afterward  I  was  able  to  reach  the  os  uteri. 
I  found  the  womb  exquisitely  sensitive ;  and  on  sounding  the  blad- 
der there  was  nothing  abnormal,  except  great  pain  when  the  sound 
passed  over  the  urethra,  the  pain  not  being  caused  by  inflammation, 
for  the  finger  in  the  vagina  did  not  feel  the  urethra  as  a  hard  and 
round  body  painful  on  being  pressed.  Injections  with  acetate  of 
lead  and  laudanum,  as  well  as  opium  and  belladonna  rectal  supposi- 
tories, enabled  me,  a  little  later,  to  examine  the  womb  without  giv- 
ing pain ;  there  was  no  ulceration  and  there  had  been  little  vaginal 
discharge.  The  pain  was  most  felt  at  the  opening  of  the  vagina, 
which  looked  sore,  red,  and  injected,  a  condition  that  accounted  for 
a  very  unusual  hardness  of  the  recto-vaginal  tissues,  a  hardness  of 
which  the  patient  was  sensible,  and  complained  of  as  something 
wrong  with  "  the  bridge."  This  was  caused  by  long-continued  con- 
gestion, although  the  parts  were  then  without  heat  or  redness.  This 
sore  state  of  the  vaginal  opening  was  relieved  by  the  application, 
twice  a  day,  of  zinc  ointment,  to  each  ounce  of  which  was  added  a 
drachm  of  diluted  hydrocyanic  acid.  Vaginitis  becoming  worse,  I 
swabbed  the  vagina  once  a  week  with  a  solution  of  nitrate  of  sil- 
ver, and  ordered  alum  and  zinc  injections ;  suppositories  did  harm, 
whether  administered  by  the  vagina  or  the  rectum.  After  thus 
treating  the  patient  for  a  few  months  the  sensations  of  burning 
and  weight  had  considerably  diminished,  but  were  often  trouble- 
sotne.  Digestion  was  much  improved  by  nitro-muriatic  acid  and 
pepsin  ;  pseudo-narcotism  and  mental  disturbance  were  not  relieved 
by  bromide  of  potassium,  but  were  much  reduced  by  henbane  and 
Indian  hemp ;  and  then  the  patient  took,  for  two  months,  three 
times  a  day,  at  meals,  the  twenty-fourth  of  a  grain  of  arseniate  of 
iron,  made  into  a  pill  with  a  fourth  of  a  grain  of  Indian  hemp — a 
combination  suitable  alike  to  the  general  nervous  derangement  and 
to  the  abdominal  neuralgia.  This  leads  me  to  the  question  of  diag- 
nosis. There  was  no  organic  disease  of  the  bladder  or  rectum,  nor 
of  the  womb,  neither  displacement  nor  ulceration  of  this  organ. 
The  disease  originated  in  vaginitis,  kept  up  by  excessive  walking 
and  drastic  medicines  at  the  (change  of  life ;  the  vaginitis  causing 
neuralgia  of  both  the  sensory  and  the  ganglionic  pelvic  nerves,  the 


THE  MENOPAUSE.  457 

neuralgia  causing  pseudo-narcotism  and  the  other  forms  of  cerebral 
disturbance  that  usuall_y  attend  the  menopause ;  the  neuralgic  ele- 
ment of  the  case  being  shown  by  the  patient's  often  feeling  the 
disturbance  to  ascend,  as  it  were,  from  the  pelvis  along  the  spinal 
column  to  the  back  part  of  the  head,  where  there  was  most  suffer- 
ing. There  was  a  gradual  recovery  of  health,  and  this  patient  has 
been  able  to  resume  her  usual  very  active  life. 

A  long  list  of  diseases  has  been  given  as  occurring  at  the  meno- 
pause. This  list  covers  nearly  all  the  ills  that  flesh  is  heir  to.  The 
majority  of  these  have  no  relations  to  the  menopause  excepting  that 
when  there  is  a  predisposition  to  any  disease,  the  disturbances  of 
the  system  due  to  the  change  would  favor  the  outbreak  at  that 
time. 

]^o  notice  need  be  taken  of  those  affections  which  are  common 
to  all  periods  of  life,  the  menopause  only  determining  the  time  of 
their  development.  When  there  exists  a  predisposition  to  any  of 
the  constitutional  diseases,  the  condition  of  nutrition  at  the  meno- 
pause, and  the  disturbed  or  unbalanced  state  of  the  nervous  system, 
favor  the  outbreak  of  these  morbid  tendencies. 


CHAPTER  XXIV. 


SENILE    ENDOMETRITIS. 


The  prevailing  opinion  is  that  cancer  is  the  only  disease  of  the 
uterus  to  be  looked  for  after  the  menopause.  There  is  a  decided 
immunity  of  the  uterus  from  inflammatory  affections  in  aged  women. 
In  the  past  and  present,  authorities  have  agreed  in  stating  that  endo- 
metritis ends  in  recovery  at  the  change  of  life.  These  opinions  are 
true  only  to  a  certain  extent.  I  have  seen  a  number  of  cases  of  en- 
dometritis which  persisted,  in  a  modified  form,  after  the  menopause, 
and  a  considerable  number  in  which  this  affection  appeared  long 
after  the  climacteric.  The  pathology  and  natural  history  of  endo- 
metritis in  advanced  life  differ  so  from  inflammatory  affections  of 
the  uterus  in  middle  life  that  I  concluded,  eighteen  or  twenty  years 
ago,  that  senile  endometritis  was  a  special,  distinct  affection  worthy 
of  more  attention  than  had  been  given  to  it.  Fritsch,  in  Billroth's 
"  Handbuch  f  iir  Frauenkrankheiten,"  treats  of  this  affection,  and 
three  or  four  others  have  referred  to  his  contributions,  and  that  is 
all  I  can  find  in  the  literature ;  even  at  the  present  time  there  are 
only  four  or  five  authors  who  make  any  allusion  to  it. 

The  subject  was  first  brought  to  my  notice  most  forcibly  in  the 
year  1875.  A  patient,  the  relative  of  a  physician,  aged  sixty-eight, 
came  under  my  care  while  suffering  from  a  sero-purulent  discharge 
from  the  uterus.  I  made  a  diagnosis  of  cancer,  but  found  I  was 
mistaken.  She  recovered,  but  I  could  see  that  this  affection  differed 
from  endometritis  as  it  occurs  in  middle  life.  From  that  time  I 
have  kept  such  cases  carefully  under  observation,  and  I  have  col- 
lected facts  sufiicient  to  complete  the  natural  history  of  the  disease. 

Pathology. — The  inflammation  may  be  limited  to  the  cervix 
alone,  but  as  a  rule  it  involves  the  entire  mucosa.  "When  it  occurs 
soon  after  the  menopause,  and  especially  if  it  is  a  continuation  of  a 
cervical  endometritis  that  existed  before  the  menstrual  function  is 
finally  suspended,  it  assumes  a  catarrhal  form  modified.  As  usually 
seen,  it  is  suppurative,  the  discharge  being  sero-purulent.     "When  it 

458 


SENILE  ENDOMETRITIS.  459 

begins  as  a  catarrh  it  gradually  progresses  to  a  suppurative  form. 
In  the  catarrhal  form,  the  discharge,  at  first  a  leucorrhoea,  diminishes, 
and  changes  from  the  translucent  tenacious  discharge  to  a  darker 
glue-like  material,  associated  with  a  sero-purulent  matter.  The 
change  results  from  the  atrophy  of  the  glands  of  ISTaboth,  which 
secrete  the  leucorrhoeal  discharge  of  catarrhal  endometritis.  The 
character  of  the  discharge  is  modified  first  by  the  atrophy  which 
follows  the  menopause,  and  by  changes  of  structure  which  are  pro- 
duced by  the  disease  itself.  It  is  not  until  the  senile  involution  is 
complete  that  the  pathological  anatomy  of  the  disease  is  fully  devel- 
oped, and  shows  the  characteristics  which  distinguish  this  affection 
from  all  other  forms  of  endometritis. 

There  is  first  a  general  atrophic  thinning  of  the  whole  mucous 
membrane.  The  epithelium  changes  from  ciliated  to  cylindrical, 
then  pavement,  and  finally  is  almost  entirely  lost.  The  surface 
around  the  os  externum  becomes  irregular,  thin,  and  shows  a  bluish- 
red  color,  which  presents  a  marked  contrast  to  the  appearance  of 
erosion  seen  in  endometritis  of  early  life.  Granulations  of  low 
vitality  appear  on  the  endometrium,  and  minute  extravasations  of 
blood  occur  and  are  seen  as  small  pigmentation  spots.  The  glands 
become  obliterated  entirely  by  the  morbid  process,  and  hence  there 
can  be  no  secretion,  but,  instead,  pus  formation.  There  is  molecular 
death  of  the  structures,  but  extensive  ulceration  is  rare.  During  the 
development  of  this  affection  the  atrophy  of  the  muscular  structure 
of  the  cervix  proceeds  faster  than  in  the  mucous  membrane  of  the 
cervix,  and  there  is  an  inversion  of  the  membrane  which  gives  a 
peculiar  appearance.  Around  the  os  externum  there  is  an  elevated 
bluish-red  ring,  which  stands  out  in  marked  contrast  to  the  normal 
mucous  membrane  of  the  vagina.  Laceration  of  the  cervix  uteri 
frequently  accompanies  senile  inflammation,  and  when  there  is  much 
scar  tissue  present  the  suffering  is  more  marked.  Stricture,  partial 
or  complete,  at  the  os  internum  or  externum  is  frequently  formed. 
Closure  of  the  os  internum  is  caused  in  some  cases  by  retroflexion 
of  the  uterus.  In  this  condition  the  discharge  is  intermittent.  For 
a  number  of  days  the  flow  stops,  and  then  a  free  discharge  of  offen- 
sive pus  takes  place.  Complete  occlusion  of  the  canal  is  caused  by 
adhesions  of  the  disintegrated  mucous  membrane — a  result  which 
follows  suppurative .  inflammation  of  the  mucosa,  but  is  rarely,  if 
ever,  present  in  catarrhal  forms  of  inflammation.  Pus  accumulates 
above  the  stricture  and  distends  the  body  of  the  uterus,  giving  rise 
to  a  condition  which  resembles  an  abscess  in  pathology,  symptoms, 
and  signs.     If  the  stricture  is  not  extensive  the  pressure  will  force 


460  DISEASES   OF   WOMEN. 

it  open,  pus  will  be  discharged,  and  there  will  be  repetitions  of  the 
closure,  accumulation,  reopening,  and  discharge.  In  most  cases,  it  is 
necessary  to  open  and  dilate  the  canal  before  relief  can  be  obtained. 
When  the  disease  has  existed  long  enough  to  destroy  the  mucous 
membrane  it  may  end  in  cicatrization,  but  there  is  a  marked  tend- 
ency to  continued  suppuration.  The  disease  can  hardly  be  called 
self-limiting. 

In  nearly  all  the  cases  that  I  have  seen  in  which  there  has  been^ 
for  a  time,  a  stenosis  of  the  canal,  the  uterus  has  become  greatly  dis- 
tended and  prolapsed  or  retroverted.  The  cavity  of  the  uterus 
measured  three  inches  and  a  half  in  one  case  and  four  inches  in  an- 
other. The  senile  atrophy  may  be  delayed  by  the  presence  of  endo- 
metritis, and  the  uterus  may  remain  larger  than  it  should  be  in  old 
age,  but  that  does  not  account  for  nor  is  it  like  the  enlargement 
from  distention.  In  the  enlargement  of  the  cavity  from  distention 
with  pus  the  walls  become  very  thin,  while  in  the  other  the  normal 
thickness  of  the  walls  continues. 

Causation. — A  continuation  of  endometritis,  acquired  before  the 
menopause,  accounts  for  a  certain  number  of  the  cases,  especially  of 
those  in  which  the  disease  is  limited  to  the  cervix.  Some  of  the 
severer  cases,  in  which  the  disease  involves  the  body  of  the  uterus, 
are  caused  by  displacements,  prolapsus,  or  retroversion,  especially 
retroversion.  Prolapsus  in  a  marked  degree  exposes  the  cervix  to 
irritation,  and,  if  it  continues  for  long,  inflammation  and  ulceration 
will  appear  around  the  os  externum,  and  the  mucous  membrane  of 
the  canal  becomes  involved.  The  atrophy  of  the  cervix  is  retarded, 
or  else  infiltration  takes  place  and  keeps  the  cervix  enlarged.  These 
cases  are  easily  controlled  in  case  the  displacement  can  be  relieved. 
Corporeal  endometritis  is  frequently  caused  by  retroversion.  The 
displacement  interrupts  the  escape  of  the  secretion  of  the  mucous 
membrane  ;  its  retention  causes  decomposition  and  inflammation  of 
a  purulent  variety.  Stricture  at  the  os  internum  would  cause  inflam- 
mation in  the  same  Nvay  as  retroversion,  and  the  two  are  often  found 
together,  but  in  the  majority  of  cases  the  occlusion  is  the  result  of 
the  inflammation. 

Acute  or  latent  gonorrhoea  may  cause  this  form  of  endometritis, 
but  I  am  not  sure  that  I  have  ever  seen  a  case  of  acute  gonorrhoea! 
endometritis  after  the  menopause.  Old  neglected  cases  I  have  seen 
several  times. 

Senile  vulvitis  and  vaginitis,  due  to  malnutrition  and  inattention 
to  cleanliness,  extend  and  cause  endometritis  in  advanced  life,  but, 
as  the  latter  very  often  is  the  cause  of  the  former,  it  is  difficult  to 


SENILE  ENDOMETRITIS.  461 

decide  in  a  given  case  whether  the  disease  began  in  the  uterus  or 
vagina.  Fibromata  of  the  uterus  act  as  a  very  important  cause  of 
the  affection.  Although  uterine  fibromata  frequently  disappear  after 
the  menopause,  the  endometritis  which  accompanies  the  neoplasm 
continues,  but  changes  from  a  catarrhal  to  a  purulent  form.  One 
patient  who  had  a  small  fibroid  passed  the  climacteric,  and  was  free 
from  all  uterine  disease  until  she  was  sixty  years  old.  She  then 
developed  an  endometritis  attended  with  such  a  profuse  sero-puru- 
lent  discharge  that  she  sought  relief  of  her  family  physician.  He 
made  a  diagnosis  of  cancer,  and  she  was  brought  to  me  for  operation, 
I  found  the  remains  of  the  fibroid  in  the  cavity  of  the  uterus.  It 
was  removed,  and  though  the  serous  element  of  the  discharge  sub- 
sided at  once,  the  endometritis  persisted,  and  only  yielded  to  treat- 
ment after  several  months. 

I  have  often  wondered  why  the  surgeons  who  find  so  many 
charges  against  fibromata,  such  as  their  danger  to  life  and  health, 
have  never  found  senile  endometritis  caused  by  them.  Perhaps  they 
have  overlooked  this  matter,  or  it  may  be  that  these  are  cases  which 
they  have  mistaken  for  cancerous. 

Fibromata  cause  endometritis  after  the  menopause  by  delaying 
senile  atrophy  and  also  by  sloughing,  which  takes  place  in  rare  cases. 
Catarrhal  endometritis  usually  accompanies  fibromata  and  changes 
to  the  purulent  variety  after  the  menopause,  as  already  stated. 

Another  curious  fact  is  that,  although  the  fibroid  that  causes  the 
metritis  may  slough  and  come  away,  or  become  pedunculated  and 
the  surgeon  remove  it,  the  metritis  continues.  This  is  the  opposite 
to  that  which  occurs  in  middle  life.  If  a  fibroid  is  removed  in  a 
young  subject,  the  endometritis  usually  subsides  when  this  cause  is 
removed.  I  saw  one  lady,  fifty-four  years  old,  who  had  a  submucous 
fibroid  of  the  uterus.  She  had  a  well-marked  endometritis,  which 
was  being  treated  without  benefit.  The  fibroid  sloughed  and  was 
completely  removed.  She  had  septicaemia,  from  which  she  recov- 
ered, but  the  purulent  endometritis  persisted,  and  only  yielded  to 
treatment  after  long-continued  efforts.  I  supposed  that  the  metritis 
in  that  case  was  obstinate  owing  to  its  being  caused  by  sepsis,  but  I 
found  that  a  like  inflammation  might  be  set  up  with  only  the  pres- 
ence of  a  fibroid  to  account  for  it.  A  patient  sixty  years  old  had, 
judging  from  her  history,  a  catarrh  of  the  uterus  at  the  menopause. 
It  continued  in  a  changed  form,  and  a  short  time  before  I  saw  her 
she  became  worse,  had  more  severe  pelvic  pains  and  tenesmus,  with 
a  very  free  sero-purulent  discharge.  I  expected  to  find  an  endome- 
tritis and  prolapsus,  but  found  a  small,  pedunculated  fibroid  that  had 


462  DISEASES  OF  WOMEN. 

been  expelled  from  the  body  of  the  uterus  and  occupied  the  dilated 
cervix.  I  removed  it,  and  the  patient  was  relieved  and  imprjoved, 
but  the  endometritis  of  the  purulent  form  continued,  and,  although 
much  less  severe,  was  difficult  to  cure. 

Syriiptoinatology . — The  symptom  which  first  attracts  attention  is 
a  discharge  which  varies  in  character  according  to  the  extent  and 
stage  of  the  inflammation.  When  a  cervical  endometritis  is  present 
at  the  menopause  the  characteristic  leucorrhcea  gradually  disappears, 
or  else  changes  to  that  of  the  senile  form  of  the  affection.  The,  te- 
nacious  secretion  of  the  cervical  glands  is  replaced  by  a  sero-puru- 
lent  discharge  which  is  more  like  a  vaginal  leucorrhoea.  The  dis- 
charge, sooner  or  later,  causes  a  subacute  or  senile  vaginitis  and 
vulvitis.  There  is  so  very  of  ten  prolapsus  of  the  vaginal  walls  and 
uterus  complicating  the  metritis  that  there  is  pelvic  tenesmus  and 
some  disturbance  of  the  vesical  and  rectal  functions. 

These  are  the  chief  symptoms  in  the  early  stage  of  this  affection 
when  prolapsus  is  the  only  complication.  When  the  utei'us  is  retro- 
verted,  and  owing  to  imperfect  drainage  the  products  of  inflamma- 
tion accumulate  and  distend  the  uterus,  there  is  more  pain  and  the 
constitutional  disturbance  is  much  more  defined.  There  is  often  a 
rise  of  temperature,  and  the  pulse  increases.  The  digestion  is  de- 
ranged and  ultimate  nutrition  impaired  in  cases  of  long  standing. 
This  is  due  to  pain,  reflex  disturbance,  and  more  especially,  perhaps, 
to  a  slight  chronic  sepsis.  The  malnutrition  increases  the  appear- 
ance of  premature  old  age,  and  the  dry,  bronzed  appearance  of  the 
skin  is  suggestive  of  malignant  disease.  In  cases  in  which  true 
stenosis  takes  place  at  the  os  internum  or  at  any  point  in  the  canal 
of  the  cervix,  the  symptoms  are  usually  very  pronounced.  The  pain 
is  acute,  and  compels  the  patient  to  rest  in  bed.  The  pain  differs 
from  that  of  acute  pelvic  inflammation  in  being  slight  at  first  but 
gradually  increasing,  while  the  pain  of  acute  disease  is  violent  at 
first  and  gradually  subsides.  The  constitutional  disturbance  is  more 
marked  in  this  condition  or  complication  than  in  any  other.  There 
is  symptomatic  fever.  In  one  of  my  patients  the  temperature 
reached  102°  F.  I  have  already  stated  that  stenosis  may  be  the 
cause  or  consequence  of  the  metritis.  The  imprisoned  secretion  and 
broken-down  tissue  cause  the  inflammation,  or  the  stenosis  may  be 
caused  by  the  inflammation.  That  accounts  for  the  fact  that  in 
some  cases  the  distention  of  the  uterus  and  the  symptoms  are  gradu- 
ally developed,  but  in  others  they  come  on  somewhat  more  abruptly. 

Physical  Signs. — Inspection  shows,  in  most  all  cases,  patches  of 
inflammatory  redness  about  the  vulva  which  are  peculiar  to  senile 


SENILE  ENDOMETRITIS.  453 

vulvitis  ;  the  contrast  between  the  red  portions  and  the  anaemic  ap- 
pearance of  the  membrane  generally  is  well  defined.  "With  the  aid 
of  the  speculum  the  signs  of  the  same  form  of  vaginitis  are  observed. 
Of  course  the  vagina  and  vulva  are  not  involved  in  all  cases,  but  as 
a  rule  they  are.  In  quite  a  few  it  has  been  limited  to  the  upper 
part  of  the  vagina,  and  mostly  the  vaginal  portion  of  the  cervical 
membrane.  The  character  of  the  discharge  is  best  studied  through 
the  speculum.  Its  character  is  of  much  value  as  a  sign.  Indeed, 
upon  this  evidence  senile  endometritis  is  distinguished  from  other 
affections  and  forms  of  inflammation,  such  as  cancer  and  gonorrhoea. 
The  appearance  of  the  discharge  differs  from  uterine  leucorrhoea  in 
being  less  tenacious,  owing  to  the  absence  in  varying  degrees  of  the 
secretion  of  the  glands  of  the  cervix.  The  color  also  indicates  the 
composition  to  be  sero-purulent,  and  in  this  it  is  more  like  the  dis- 
charge in  specific  inflammation,  and  is  similar  in  appearance  to  that 
found  in  the  early  stage  of  cancer.  The  differentiation  between  the 
discharge  in  senile  endometritis,  specific  metritis,  and  cancer  must  be 
made  by  the  microscope  if  one  would  make  the  distinction  at  once — 
i.  e.,  without  waiting  for  the  full  development  of  the  history.  In 
senile  metritis,  pus,  serum,  disintegrated  tissue,  and  changed  or 
broken-down  epithelium  and  bacteria  are  found.  In  cancer  the  dis- 
charge is  sero-sanguinolent,  and  later  in  the  progress  of  the  disease 
contains  broken-down  necrotic  tissue  and  elements  of  the  neoplasm. 
The  gonorrhceal  discharge  can  be  distinguished  by  the  specific  germ 
of  that  affection.  "Without  the  aid  of  the  microscope  it  is  impossible 
to  make  a  positive  diagnosis  between  the  specific  or  non-specific 
origin  of  senile  endometritis,  but  fortunately  the  indications  for 
treatment  are  the  same  whatever  the  cause  of  the  affection  may  be. 
The  history  may  show  that  gonorrhoea  is  the  probable  cause,  espe- 
cially if  the  disease  comes  on  abruptly,  was  acute  at  first,  and  in- 
volved the  vulva  and  urethra  first. 

The  differentiation  between  this  affection  and  cancer  of  the  cer- 
vix is  made  by  observing  that  in  cervical  endometritis  there  is  the 
characteristic  discharge  and  degeneration  and  atrophy  of  the  mucous 
membrane,  and  in  cancer  there  is,  in  addition  to  the  discharge,  infil- 
tration of  the  tissues — i.  e.,  neoplastic  growth.  "When  the  disease  is 
fully  developed  in  the  body  of  the  uterus  the  clinical  history  resem- 
bles malignant  disease,  but  can  be  readily  diagnosticated  by  the  fact 
that  pus  in  quantity  accumulates  in  the  cavity  of  the  body  of  the 
uterus  in  metritis,  while  that  never  occurs  in  cancer.  By  aspirating 
the  uterine  cavity  the  material  drawn  off  will  be  pus,  and  perhaps  a 
little  blood,  while  in  cancer  it  is  serum,  blood,  and  broken-down 


464  DISEASES  OF  WOMEN. 

cancer  tissue.  The  aspiration  is  easily  made  by  using  a  small  curved 
pipette  with  a  rubber  bulb  at  the  end.  By  compressing  the  bulb 
and  introducing  the  pipette  and  removing  the  pressure,  enough  ma- 
terial can  be  withdrawn  to  show  its  character  and  decide  the  diag- 
nosis. Of  course,  if  a  microscopical  examination  can  be  obtained  by 
an  expert  the  diagnosis  can  be  made  much  more  certainly.  The 
history  of  the  progress  of  the  disease  aids  in  the  diagnosis.  Cancer 
progresses  steadily,  but  metritis  continues  about  the  same,  or  slowly 
yields  to  such  treatment  as  will  have  no  effect  in  retarding  or  curing 
cancer.  Adenoma  may  be  mistaken  for  senile  endometritis,  but  the 
differential  diagnosis  is  easily  made.  Adenoma  uteri  occurs  earlier 
in  life,  generally  about  the  menopause,  and  is  attended  with  monor- 
rhagia or  metrorrhagia  as  the  most  marked  symptom.  This  differ- 
ence is  diagnostic,  because  menorrhagia  does  not  occur  in  this  form 
of  metritis.  There  is  not,  as  a  rule,  any  purulent  discharge  in  adeno- 
ma. By  using  a  small  curette  a  portion  of  the  adenomatous  growth 
can  be  removed  for  examination  which  will  complete  the  diagnosis. 
Treatment. — When  the  disease  is  confined  to  the  cervix  a  douche 
of  a  solution  of  borax,  three  drachms  to  the  quart,  gives  much  relief 
and  prevents  the  discharge  from  keeping  up  vaginitis.  Sulphate  of 
zinc,  one  drachm  to  the  quart  of  water,  is  very  effective  in  case  the 
borax  fails.  The  hot- water  douche,  as  used  in  uterine  disease  gener- 
ally, is  not  of  much  value  in  the  senile  form.  If  there  is  any  pro- 
lapsus or  other  displacement  it  must  be  corrected  by  the  use  of 
medicated  tampons  until  the  inflammation  is  relieved.  Sterilized 
absorbent  cotton  covered  with  boroglyceride,  glycerin  and  tannin,  or 
white  vaseline  answer  the  purpose.  I  have  tried  prepared  wool  for 
tampons,  but  it  is  more  irritating  and  has  to  be  changed  more  fre- 
quently. Astringent  and  alterative  applications  are  useful  in  reliev- 
ing the  cervical  inflammation,  but  any  caustics,  even  the  mildest,  do 
harm  rather  than  good.  I  have  most  faithfully  tried  carbolic  acid 
and  iodine,  which  are  so  effective  in  ordinary  metritis,  but  these 
agents  are  not  satisfactory  in  the  senile  form  of  the  disease.  One 
or  two  applications  of  a  combination  of  carbolic  acid  and  tincture  of 
iodine  may  do  good,  but  it  should  not  be  repeated  many  times.  All 
caustics  rather  encourage  the  breaking  down  of  the  atrophied  tissue, 
and  when  the  slough  separates  the  surface  left  does  not  incline  to 
heal,  but  to  suppurate.  The  best  results  liave  been  obtained  from 
the  use  of  boroglyceride  with  tannin,  glycerin  and  tannin,  fluid 
extract  of  hydrastis  canadensis  and  a  mild  solution  of  acetic  acid, 
one  drachm  to  two  ounces.  The  canal  should  be  thoroughly  washed 
out  with  clean  water  and  the  application  made  with  a  pipette. 


SENILE  ENDOMETRITIS.  4C5 

I  generally  begin  the  local  treatment  with  dilute  acetic  acid  or 
tincture  of  iodine  four  parts,  and  carbolic  one  part;  an  application 
of  either  of  the  above  twice  in  the  first  week.  This  answers  the 
best  when  the  discharge  is  very  free.  Following  this,  a  mixture  of 
twenty  grains  of  tannic  acid  in  an  ounce  of  boroglyceride.  This  is  a 
thickish  material  which  is  difficult  to  apply.  I  manage  by  warming 
the  mixture  and  using  a  pipette  wjth  an  opening  in  the  end  as  large 
as  the  size  of  the  glass  tube  will  admit.  Tannin  and  glycerin  were 
used  almost  altogether  some  years  ago  ;  now  I  prefer  the  boro- 
glyceride and  tannin.  The  fluid  extract  of  hydrastis  canadensis  is 
easily  used  and  has  a  very  good  effect,  and  I  fall  back  on  that  when 
the  others  do  not  do  well.  Iodoform  is  the  most  efficient,  and  when 
it  can  be  freely  and  properly  applied  supersedes  all  other  agents. 
Indeed,  were  it  not  for  its  being  difficult  of  application  to  the  canal 
of  the  uterus  it  would  meet  all  requirements.  I  have  only  used 
other  remedies,  such  as  I  have  mentioned,  because  they  were  so 
much  more  easily  applied  and  have  not  the  offensive  odor  of  iodo- 
form. I  was  first  led  to  nse  iodoform  in  senile  endometritis  by  ob- 
serving its  remarkable  effects  in  the  treatment  of  ulcers  in  general 
surgery.  Dr.  Fordyce  Barker  used  it  in  cases  of  cancer  of  the  uterus 
with  great  benefit.  He  used  iodoform  suppositories  made  in  con- 
venient form  to  introduce  into  the  uterus.  The  results  that  he  ob- 
tained were  so  favorable  that  I  am  now  inclined  to  believe  that  some 
of  the  cases  that  he  believed  to  be  cancers  were  really  cases  of  senile 
endometritis.  Many  gynsecologists  have  made  that  mistake  in 
diagnosis,  and  it  is  no  disparagement  to  suppose  that  Dr.  Barker 
may  have  occasionally  fallen  into  the  same  error.  I  presumed  that 
the  effect  of  iodoform  was  due  in  a  measure  to  its  antiseptic  quali- 
ties, but  learned  that  it  was  not  a  germicide  to  any  degree  sufficient 
to  explain  its  effect  in  checking  suppurative  inflammation.  The 
"  Bulletin  General  de  Therapeutique  "  contains  a  full  discussion  of 
the  subject. 

"  Maurel,  who  is  well  known  by  his  researches  on  the  leucocytes, 
has  undertaken  to  solve  the  problem  why  iodoform,  which  is  so 
efficacious  in  preventing  or  suppressing  suppuration,  should  appar- 
ently have  so  little  action  on  the  pyogenic  staphylococci. 

"  He  first  experimented  with  a  virulent  culture  (on  gelose)  of 
staphylococci  in  the  presence  of  leucocytes.  The  latter  speedily 
absorbed  the  staphylococci,  but  succumbed  in  less  than  two  hours. 
In  the  control  field,  however,  they  accomplish  their  evolution  and 
live  from  twelve  to  twenty-four  hours.  Maurel  finds  that  the  death 
of  the  leucocytes  under  the  influence  of  the  pus  micro-organisms  is 
81 


4:^6  DISEASES   OF  WOMEN. 

due  to  a  toxiue  contained  in  tlie  bodies  of  these  microbes,  not  to  the 
mechanical  action  of  the  staphylococcus  or  to  the  products  which 
the  latter  yields  up  to  its  environment.  Under  the  influence  of 
these  same  staphylococci,  the  red  corpuscles  become  diffluent  in 
fifteen  honrs  and  then  disappear. 

"  Another  series  of  experiinents  were  made  by  subjecting  the 
fiffured  elements  of  the  blood  to  the  action  of  iodoform  in  the  dos- 
age  of  ten  to  two  and  a  half  per  kilogramme  of  blood,  Neither  the 
smaller  nor  the  larger  doses  were  found  to  be  toxic  to  the  leuco- 
cytes ;  the  vital  activity  of  these  latter  was,  on  the  contrary,  aug- 
mented, and  the  action  on  the  red  globules  was  nil. 

"  A  third  series  of  experiments  show  iodoform  to  be  with- 
out marked  action  on  cultures  of  the  staphylococcus  aureus  and 
albus. 

"  In  a  fourth  series  of  researches  Maurel  subjected  both  the  leu- 
cocytes of  human  blood  and  cultures  of  the  staphylococcus  to  the 
action  of  iodoform  in  varying  proportions  and  under  varying  con- 
ditions.    His  conclusions  are  as  follows  : 

"  1.  Iodoform  attenuates  the  virulence  of  the  staphylococcus. 
While  in  the  virulent  state,  this  micrococcus  kills  our  leucocytes  in 
less  than  two  hours ;  when  it  is  subjected  along  with  the  leucocytes 
to  the  influence  of  iodoform,  the  latter  preserve  their  movements 
for  eight  hours  at  least,  and  even  complete  their  evolution. 

"  2.  The  staphylococci,  which  have  thus  lost  a  great  part  of  their 
virulence  (and  to  such  a  degree  that  they  are  seemingly  devoured  by 
the  leucocytes  with  impunity),  keep  all  their  reproductive  energy  un- 
impaired, so  that  virulence  and  the  power  of  reproduction  are  inde- 
pendent properties. 

"  A  final  conclusion  is  deduced  that  it  is  in  both  these  ways — ac- 
cording to  Maurel  it  is  by  augmenting  the  energy  of  the  leucocytes 
and  attenuating  the  virulence  of  the  pus  microbes — that  iodoform 
opposes  suppuration,  which  is,  in  the  language  of  bacteriology,  a 
massive  slaughtering  of  the  leucocytes." 

These  teachings  are  in  harmony  with  clinical  experience  as  to 
the  benefits  of  iodoform  in  preventing  or  arresting  suppuration. 

There  is  considerable  difliculty  in  applying  iodoform  to  the  cav- 
ity of  the  body  of  the  uterus  in  sufficient  quantity  to  be  effective. 
Suppositories  made  with  cacao  butter  are  not  retained  in  the  cervix, 
and,  although  they  remain  in  the  cavity  of  the  body  for  a  time,  there 
is  not  enough  retained  to  give  the  full  effect.  I  have  used  a  solution 
in  boiled  linseed  oil,  and  also  an  ether  solution,  but  the  latter  causes 
much  irritation,  and  the  former  docs  not  hold  enough  of  the  iodo- 


SENILE  ENDOMETRITIS.  467 

form.  The  best  is  the  dry  fine  powder,  whicli  can  be  introduced 
through  a  small  cannula.  The  next  best  (and  more  easily  intro- 
duced) is  the  fine  powder  held  in  suspension  in  acacia  and  water  by 
agitation  and  then  instilled  with  a  pipette. 

When  the  disease  (limited  to  the  cervix)  is  complicated  with  scar 
tissue  resulting  from  old  lacerations,  I  have  operated  with  the  result 
of  relieving  some  of  the  neuralgic  pain,  and  with  benefit  to  the  in- 
flammation. It  is  difficult  to  get  good  and  prompt  union.  In  fact, 
some  of  the  operations  have  been  failures. 

The  treatment  of  the  corporeal  form  of  this  affection  is  rendered 
more  difficult  by  certain  complications,  such  as  prolapsus,  stenosis  of 
the  canal,  or  retroflexion.  Complete  closure  of  the  canal,  of  course, 
must  be  relieved  first  by  dilatation,  to  afford  room  for  washing  out 
the  uterus  and  subsequent  drainage.  When  the  stricture  is  at  the  os 
internum,  time  and  patience  are  necessary  to  open  the  canal.  This, 
if  possible,  should  be  accomplished  by  dilating  the  canal  below  the 
stricture  and  then  pushing  a  very  fine  probe  through  the  stricture. 
There  is  danger  in  puncturing  the  stricture  with  a  knife,  because  it 
is  difficult  to  determine  the  direction  of  the  canal,  and  hence  danger 
of  puncturing  the  wall  of  the  uterus.  Gradual  dilatation  is  best. 
Owing  to  the  friable  condition  of  the  uterine  tissue  laceration  is  sure 
to  occur  if  forcible  dilatation  is  practiced.  When  an  opening  has 
been  made  large  enough  to  pass  a  uterine  sound,  a  piece  of  gauze 
should  be  introduced  to  keep  the  parts  from  contracting.  Better 
still  is  a  tent  of  elm  bark,  carbolized  before  use.  This  tent  is  bland, 
sterile,  and  swells  a  little,  which  keeps  up  dilatation.  When  the 
cervix  is  dilatable,  the  canal  should  be  made  large  enough  to  admit 
a  reflex  catheter.  The  nterus  should  be  washed  out  with  a  five-per- 
cent solution  of  carbolic  acid  and  then  packed  with  iodoform  gauze. 
The  packing  should  be  left  in  forty-eight  hours,  if  there  is  no  severe 
pain  and  rise  of  temperature.  Upon  removing  the  gauze  the  uterus 
should  be  washed  out  with  boiled  water,  and  iodoform  powder  in- 
troduced in  the  way  described  in  the  treatment  of  cervical  endome- 
tritis. Owing  to  the  difficulty  of  handling  iodoform  I  have  used 
peroxide  of  hydrogen  and  found  it  very  useful.  When  a  reliable 
preparation  can  be  obtained  it  gives  most  satisfactory  results,  pro- 
viding it  is  used  twice  or  three  times  a  day. 

Owing  to  the  difficulty  of  obtaining  reliable  preparations  of  per- 
oxide of  hydrogen,  and  the  fact  that  it  is  easily  decomposed  by  heat 
and  exposure,  I  have  lately  used  a  preparation  made  by  McKesson 
&  Robbins.  It  is  an  aqueous  solution  of  dioxide  of  hydrogen.  It 
is  called  pyrozone.     A  three-per-cent  solution  is  the  one  which  I 


468  DISEASES  OP  WOMEN. 

have  used.  I  have  not  had  sufficient  experience  so  far  to  enable  me 
to  say  that  this  pyrozone  is  all  tliat  it  is  claimed  to  be. 

In  cases  complicated  with  retroversion  the  malposition  must  be 
corrected  in  order  to  be  able  to  wash  out  the  uterus  thoroughly  and 
to  keep  up  drainage.  The  treatment  of  retroversion  is  very  difficult 
when  the  vagina  is  contracted,  as  it  usually  is  after  the  climacteric — 
in  fact,  it  is  impossible  to  replace  the  thin-walled  uterus  that  is  dis- 
tended with  the  products  of  inflammation.  Thorough  dilatation 
and  evacuation  must  first  be  made,  and  then  by  the  use  of  a  tampon 
or  a  soft  ring  pessary  the  posterior  vaginal  wall  may  be  carried  back- 
ward far  enough  to  keep  the  fundus  uteri  from  falling  downward 
below  the  level  of  the  cervix.  Free  drainage  may  be  obtained  al- 
thougli  the  uterus  may  still  be  retroverted  in  a  slight  degree.  Pro- 
lapsus also  requires  to  be  corrected. 

Both  patient  and  surgeon  are  likely  to  become  discouraged  with 
the  treatment,  which  is  sure  to  be  tedious,  especially  if  not  well  un- 
derstood. This  has  raised  the  question  in  my  mind  whether  hys- 
terectomy would  not  be  justifiable  in  the  worst  cases.  I  have  seen 
the  uterus  removed,  supposedly  for  cancer,  but  really  in  senile  en- 
dometritis, and  the  results  have  been  good.  Still  I  would  prefer  to 
employ  the  treatment  recommended  here,  and  not  until  that  had 
failed  would  I  resort  to  hysterectomy. 

In  cases  of  senile  endometritis  complicated  with  complete  pro- 
lapsus, vaginal  hysterectomy  is  the  proper  treatment  in  all  cases  ex- 
cepting in  those  whose  general  health  presents  a  contra-indication. 
Dr.  Edebohls  has  done  hysterectomy  in  cases  of  complete  prolapsus, 
and  ahliough  I  have  succeeded  in  relieving  such  displacement  in  the 
majority  of  cases  without  removing  the  uterus,  I  resort  to  hysterec- 
tomy without  the  least  hesitation,  and  with  confidence  in  the  results, 
in  cases  of  senile  endometritis  and  complete  prolapsus. 


CHAPTER  XXY. 


DISEASES    OF   THE   OVAKIES. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  OVARY. 

The  ovaries  are  two  bodies,  in  shape  somewhat  like  an  ahnond, 
situated  in  the  pelvic  cavity,  one  on  either  side  of  the  uterus,  and 
removed  from  it  about  one  inch.  They  are  connected  with  that 
organ  by  the  Fallopian  tubes  and  the  ovarian  ligaments.  Before  birth 
the  ovaries  are  on  a  level  with  the  iliac  fossa,  and  it  is  not  until  the 
tenth  year  of  life  that  they  reach  what  may  be  considered  their  per- 
manent position — that  is,  the  lateral  and  posterior  part  of  the  true 
pelvis.  Hasse,  of  Breslau,  in  a  female  cadaver  frozen  in  the  upright 
position,  found  that  the  long  axis  of  both  ovaries  ran  outward  and 
forward,  forming  with  the  transverse  axis  of  the  uterus  an 

one  half  of  the  organ  project- 
ing above  the  plane  of  the 
pelvic  brim.  Schultze,  on 
the  contrary,  regards  the 
long  axis  of  the  ovaries 
as  being  in  an  antero-pos- 
terior  position,  as  shown 
in  Fig.  208.  It  must  be 
borne  in  mind,  however, 
that  the  position  of  the 
ovaries  is  not  a  fixed 
one  ;  their  relation  to  the 
uterus  and  the  other  pel- 
vic organs  is  such  that,  when  any  one  of  these  is  displaced,  a  change 
in  the  position  of  the  ovaries  will  of  necessity  occur ;  thus  the  full 
or  empty  bladder  or  rectum  acting  upon  the  uterus  will  tend  to  push 
the  ovaries  in  one  direction  or  another.  The  average  dimensions  of 
each  ovary  are  :  Length,  one  inch  and  a  quarter ;  width,  three  quar- 
ters of  an  inch ;  and  thickness,  half  an  inch.  Its  weight  is  about 
eighty  grains.  As  its  position  changes,  so  do  also  the  measurements 
here  given.  It  is  probably  in  its  most  perfect  condition  in  the  vir- 
gin at  about  the  age  of  puberty.  According  to  Hennig's  observa- 
tions, the  ovary  increases  in  length  during  pregnancy,  but  neither  its 

'  4G9 


Fig.  208. — The  fundus  uteri  and  ovaries  seen  through 
The  pelvic  brim  (His).  The  cross  is  in  the  center 
of  the  pelvis  and  on  the  fundus ;  o,  o,  ovaries 
encircled  by  the  Fallopian  tubes  in  their  backward 
sweep. 


470 


DISEASES  OF  WOMEN. 


breadth  nor  thickness  exceeds  that  found  in  the  virgin.  When  preg- 
nancy has  ceased  the  ovaries  become  smaller,  and  do  not  at  any  time 
subsequently  regain  the  dimensions  possessed  by  the  virgin  ovary. 

The  relation  of  the  ovaries  to  the  broad  ligament  is  a  matter  of 
great  importance  and  interest.  These  ligaments  consist  of  two  folds 
or  layers  of  the  peritonaeum,  with  a  lining  of  muscular  tissue,  be- 
tween which  lie  the  uterus  and  its  appendages.    The  ovaries,  however, 


Od' 


Fig.  209. — The  ovary  and  its  ligaments  (Henle).  Ut,  uterus ;  Od,  fallopian  tube ; 
/o,  ovarian  ligament ;  ip,  infundibulo-pelvic  ligament ;  io,  infundibulo-ovarian  liga- 
ment ;  Fo,  fimbria  ovarica ;  Po,  parovarium. 

are  not  situated  between  these  two  layers,  but  are  suspended,  so  to 
speak,  from  the  posterior  surface  of  the  posterior  layer,  and  are  there- 
fore entirely  behind  both  layers  or  folds  of  peritonaeum,  which  form 
the  broad  ligament,  but  attached  to  the  posterior  layer  by  their  long 
axis,  this  attached  portion  of  the  ovary  being  termed  the  liilum.  In 
the  anterior  face  of  the  posterior  layer  of  the  broad  ligament,  on  either 
side,  is  an  opening  or  slit  through  which  the  blood-vessels,  nerves, 
and  lymjihatics  of  the  ovary  pass.  The  ovarian  ligaments  which  con- 
nect the  body  of  the  uterus  and  the  ovaries,  leaving  the  former  at  a 
point  between  the  Fallopian  tubes  and  the  round  ligaments,  after 
running  for  some  distance  between  the  two  layers  of  the  broad  liga- 
ment, pass  out  l)y  these  openings  in  the  posterior  layers  to  the  ovaries. 
These  ovarian  ligaments  are  about  one  inch  in  length,  and  are  com- 
posed of  tibrons  tissue,  into  which  some  of  the  uterine  muscular  tis- 
sue is  prolonged  (Fig.  209).     Fach  ovary  is  also  connected  with  the 


DISEASES  OF  THE  OVARIES. 


471 


corresponding  Fallopian  tube  by  one  of  its  fimbriae,  and  through  this 
to  the  pelvis  by  means  of  the  inf undibulo-pelvic  ligament — a  ligament 
about  two  thirds  of  an  inch  in  length,  running  from  the  outer  end  of 
the  Fallopian  tube  to  the  wall  of  the  pelvis.  Thus  the  ovary  is  main- 
tained in  its  position — subject,  however,  to  considerable  alteration — 

by  the  broad,  the  ovarian,  and  the  in- 
fundibulo-pelvic  ligaments. 

The  supply  of  blood  to  the  ovaries 
is  by  the  ovarian  artery,  a  branch  of  the 
abdominal  aorta  corresponding  to  the 
spermatic  artery  of  the  male. 


Fig.  210. — The  ovarian,  uterine,  and  vaginal 
arteries  (Hyrtl). 


After  this  artery  enters  the  pelvis  it  passes  between  the  layers  of 
the  broad  ligament  in  a  direction  toward  the  upper  angle  of  the  uterus ; 
its  course  is  parallel  to,  though  below,  the  Fallopian  tube.     It  sends 


472  DISEASES  OF   WOMEN. 

branches  to  the  ovary,  which  pass  out  from  between  the  layers  of  the 
broad  hgament  to  the  ovary  through  the  opening  in  the  posterior 
layer  already  referred  to.  Other  branches  supply  the  Fallopian  tube 
and  anastomose  with  the  uterine  artery.  The  venous  blood  of  the 
ovary  passes  into  the  ovarian  plexus,  sometimes  spoken  of  as  the  pam- 
piniform plexus,  which  is  situated  between  the  layers  of  the  broad 
ligament,  and  is  thence  carried  to  the  inferior  vena  cava  on  the  right 
side,  and  to  the  renal  vein  on  the  left.  These  veins,  which  form 
a  network  in  the  ovary,  have,  according  to  Kouget,  associated  with 
them  muscular  trabeculse,  which,  in  their  contraction,  prevent  the 
passage  of  the  blood  from  the  ovary  into  the  large  venous  trunks,  and 
thus  permit  of  what  may  be  termed  an  erection  of  the  ovary.  It  is 
probable  that  during  the  act  of  coition  such  a  condition  takes  place 
in  the  ovary,  increasing  its  size  to  a  considerable  extent,  and  causing 
it  to  become  firmer  and  more  sensitive.  Rouget  describes  the  lym- 
phatics of  the  ovary  as  united  into  six  or  eight  trunks,  which  accom- 
pany the  ovarian  artery,  and  discharge  into  the  middle  and  superior 
lumbar  lymphatic  ganglia.  The  lymphatic  circulation  becomes  of  spe- 
cial importance  in  explaining  the  method  by  which,  under  certain  con- 
ditions, septic  matter  is  absorbed,  producing  septicaemia.  The  ovarian 
and  uterine  plexuses  communicate,  as  do  the  arteries  of  the  same  names. 

The  nerves  of  the  ovaries,  as  well  as  those  of  the  nterus,  arise  from 
the  cceliac  plexus,  which  is  in  part  distributed  to  the  ovaries  and  to 
the  spermatic  ganglia.  According  to  Frankenhauser,  the  superior 
mesenteric  plexus  supplies  these  spermatic  ganglia,  which  Courty 
suggests  would  be  better  called  genital  ganglia.  These  ganglia,  four 
in  number,  are  supplied  from  the  sympathetic  through  two  large 
branches,  and  in  turn  supply  the  ovaries  through  a  considerable 
number  of  branches. 

Development  of  the  Ovary. — At  a  very  early  period  in  the  devel- 
opment of  the  foetus  two  bodies  are  formed  in  the  abdominal  cavity, 
one  on  each  side  of  the  spinal  column  ;  these  are  the  Wolffian  bodies, 
the  function  of  which  is  undoubtedly  similar  to  that  of  the  adult 
kidney.  According  to  Coste,  they  are  fully  formed  at  the  end  of 
the  first  month,  and  according  to  Longet,  are  hardly  visible  after 
the  second  month.  While  these  organs  are  in  a  state  of  activity  the 
kidneys  are  formed  behind  them,  and  at  the  same  time  two  other 
organs  appear  in  front  of  the  Wolffian  bodies,  and  on  their  inner 
side  ;  these  are  the  internal  organs  of  generation — the  testicles  in  the 
male  and  the  ovaries  in  the  female.  The  detailed  history  of  the 
development  of  these  organs  is  as  follows :  At  a  very  early  stage  of 
development — in  the  chick  as  early  as  the  third  day — the  cells  of 


DISEASES  OF  THE   OVARIES. 


473 


the  raesoblast  form  a  longitudinal  cord  in  the  mesoblast,  one  on  each 
side  of  the  body,  and  just  external  to  the  protovertebrae,  which  are 
also  formed  from  this  same  layer.  These  cords  are  at  first  solid,  but 
a  cavity  gradually  forms  within  them,  and  they  become  the  Wolffian 
ducts.  From  this  primitive  tube  diverticula  are  given  off,  forming, 
as  it  were,  blind  tubes,  into  which  blood-vessels  enter,  and  with  the 
diverticula  form  the  Wolffian  bodies,  one  upon  either  side.  Another 
portion  of  the  mesoblast  projecting  in  the  form  of  a  ridge,  and  cov- 
ered with  "  germ  epithelium  "  on  the  inner  side  of  the  Wolffian  body 
— that  is,  toward  the  median  line — becomes  the  testicle  or  the  ovary, 
according  as  the  individual  is  to  be  of  the  male  or  female  sex.  On 
the  outer  wall  of  the  Wolffian  body  an  involution  takes  place  from 
the  pleuro-peritoneal  cavity,  forming  at  first  a  furrow,  but  later,  by 
the  union  of  its  edges,  a  duct,  which  is  known  as  Miiller's  duct.  In 
the  female  these  ducts  form  the  Fallopian  tubes,  the  uterus,  and  the 
vagina,  while  in  the  male  they  have  no  special  function,  although 
the  upper  part  remains  as  the  hydatid  of  Morgagni,  and  the  lower 
as  the  prostatic  pouch,  the  uterus  masculinus,  or  sinus  pocularis. 
While  the  Wolffian  ducts  in  the  male  form  the  body  and  globus 
minor  of  the  epididymis,  the  vas  deferens,  and  the  ejaculatory  duct, 
in  the  female  the  lower  part  only  remains  to  form  the  duct  of  Gaert- 
ner.     If  the  broad  ligament  is  examined  with  transmitted  light,  a 

cone  is  seen  nearly  an 
Q/iFTM^PUCr        inch    in    breadth,    of 
^       whitish,  more  or  less 
convoluted    tubes,  in 
number  about  twenty,  each 
of  which  is  lined  with  cili- 
ated epithelium  and  contains 
a  clear  fluid  (see  Fig.  209). 
This  is   the    parovarium    of 
Kobelt,    or     the    organ    of 
Rosenmiiller,     and     is     the 
remnant    of     the    Wolffian 
body    of    fa3tal    life.      The 
pathological  degeneration  of 
these  tubes  produces  the  par- 
ovarian cystic  tumor.     The 
ovary  itself  consists   of  the 
oophoron  and  the  paroophoron  ;  the  latter  must  not  be  confounded 
with  the  parovarium.     Fig.   211,  taken  from  Bland   Sutton,   will 
make  this  distinction  clear.    The  paroophoron  is  made  up  of  fibrous 


Fig.  211. — Diagram  representing  tlie  cyst-regions 
of  the  ovary  (from  Bland-Sutton). 


474  DISEASES  OF   WOMEN. 

tissue  and  blood-vessels.     In   it  are  developed  paroophoritic  cysts, 
which  will  be  described  later. 

Minute  Anatomy  of  the  Ovary.— The  fact  that  the  ovary  is  situ- 
ated behind  both  layers  of  the  broad  ligament,  and  attached  only  at 
the  hilum,  has  already  been  referred  to.  From  this  it  follows  that 
the  posterior  surface  of  the  ovary  is  not  covered  by  peritonaeum. 
The  more  thorough  and  skillful  investigations  of  recent  years  have 
satisfactorily  demonstrated  that  the  surface  of  the  ovary  is  in  appear- 
ance and  structure  very  different  from  the  peritonaeum.  While  the 
epithelium  which  covers  the  broad  ligament  is  transparent  and  flat- 
tened, that  which  forms  the  surface  of  the  ovary  is  granular  in  ap- 
pearance and  columnar  in  form.  This  marked  difference  has  sug- 
gested to  some  that  the  covering  of  the  ovary  was  a  mucous  rather 
than  a  serous  membrane.  These  columnar  cells  are  very  similar  to 
those  lining  the  Fallopian  tubes,  except  that  the  cilia  which  are 
present  in  the  latter  are  wanting  in  the  former.  It  is  an  error  to 
regard  these  superficial  cells  of  the  ovary,  which  are  arranged  in  a 
single  layer,  as  in  any  sense  a  covering  of  the  ovary.  They  are  in 
reality  an  integral  part  of  the  ovary,  and,  as  the  name  "  germ  epi- 
thelium "  implies,  their  function  is  a  most  important  one,  being 
none  less  than  the  formation  of  the  ova  by  a  modification  of  their 
structure,  as  has  been  so  well  described  by  Waldeyer. 

Beneath  this  layer  of  germ  epithelium  is  the  tunica  albuginea. 
This  is  made  up  of  bundles  of  spindle-shaped  cells,  arranged,  accord- 
ing to  Ilenle,  in  three  layers,  the  outer  and  inner  ones  being  longi- 
tudinal, and  the  middle  one  circular.  The  albuginea  contains  no 
Graafian  follicles.  The  third  layer — that  is,  the  one  next  to  the 
albuginea — is  what  Schron  has  described  as  the  cortical  layer.  This 
contains  the  smallest  of  the  Graafian  follicles  arranged  in  groups, 
but  separated  by  the  stroma  of  the  ovary,  this  latter  being  made  up 
of  bundles  of  spindle-shaped  cells,  some  short  and  others  long,  each 
having  an  oval  nucleus,  and  being  probably  young  connective-tissue 
cells.  The  Graafian  follicles  of  the  cortical  layer  are  spherical  or 
slightly  oval  bodies,  with  a  diameter  of  one  one  thousandth  of  an  inch, 
and  have  as  their  external  portion  a  delicate  membi-anc — the  mem- 
brana  propria.  Lining  this  is  the  membrana  granulosa,  a  layer  of 
flat,  transparent  epithelial  cells,  with  oval  nuclei.  Within  this,  and 
occupying  the  entire  cavity  of  the  follicle,  is  a  spherical  cell— the 
ovum.  The  ovum  is  a  collection  of  granular  protoplasm  containing 
a  spherical  or  oval  nucleus,  the  germinal  vesicle,  and  this,  in  turn,  a 
body  known  as  the  germinal  spot.  Below  this  cortical  layer,  im- 
bedded in  the  stroma,  are  Graafian  follicles  of  almost  every  conceiv- 


DISEASES   OP   THE   OVARIES. 


475 


able  size.  While  the  older  anatomists  thought  the  total  number  of 
follicles  in  an  ovary  did  not  exceed  twenty,  this  nuuibei-  being  all 
that  could  be  seen  by  the  unaided  eye,  some  of  the  more  recent 
authorities  have  placed  the  number  at  six  hundred  thousand.  As 
follicles  ruptui'e  and  discharge  each  month  for  a  long  series  of  years, 
the  estimate  of  the  earlier  writers  is  undoubtedly  too  low — probably 


EiG.  212. — Section  of  the  ovary  of  a  bitch  (Waldeyer).     a,  germ  epithelium  ;  d,  ovum  ; 
i,  membrana  granulosa ;  /,  vitelline  membrane,  vitellus,  germinal  vesicle,  and  spot. 

as  much  too  low  as  that  of  some  of  the  recent  ones  is  too  high.  All 
the  layers  thus  far  described  constitute  the  parenchyma  of  the  ovary. 
Between  this  and  the  hilum  is  the  vascular  zone,  which  contains  no 
follicles,  but  is  made  up  of  bundles  of  connective  tissue  and  bundles 
of  non-striped  muscular  tissue,  which  are  directly  continuous  with 
the  corresponding  tissues  of  the  broad  ligament.     It  is  in  this  vas- 


476  DISEASES  OP  WOMEN. 

culur  zone  that  the  blood-vessels  of  the  ovary  are  found,  and,  indeed, 
give  to  it  the  name  which  characterizes  it. 

The  Graafian  follicle  of  medium  size  is,  hke  that  of  the  cortical 
layer,  made  up  of  a  membrana  propria  and  a  membrana  granulosa, 
and  contains  an  ovum.  The  ovum  is,  however,  larger  than  that  of 
the  cortical  follicles,  and  is  limited  by  a  thin  membrane,  the  zona 
pellucida  or  vitelline  membrane.  This  is  believed  to  be  formed  by 
the  cells  of  the  membrana  granulosa.  As  the  follicle  increases  in 
size  the  ovum  does  not  increase  correspondingly,  so  that,  while  for 
a  considerable  time  it  completely  tilled  the  cavity,  now  it  does  not 
do  so,  and  the  space  between  it  and  the  membrana  granulosa  contains 
an  albuminous  tiuid — the  liquor  folliculi.  It  should  be  stated  that 
a  Graafian  follicle,  while  it  usually  contains  but  one  ovum,  does  some- 
times contain  two  or  even  three  ova.  At  one  part  of  the  membrana 
granulosa  the  cells  are  more  abundant  than  elsewhere,  forming  a 
mound  which  is  known  as  the  discus  or  cumulus  proligerus  ;  in  the 
center  of  this  accumulation  of  cells  the  ovum  is  imbedded.  Some  of 
the  Graafian  follicles  reach  maturity,  so  far  as  can  be  told  from  their 
size  and  appearance,  and  undergo  degeneration  before  the  age  of 
puberty  is  attained.  Some  of  the  small  follicles  also  degenerate, 
never  reaching  maturity.  The  number  of  follicles  which  thus  de- 
generate is  by  no  means  inconsiderable,  and  a  knowledge  of  this  fact, 
and  that  at  each  menstrual  epoch  a  follicle  ruptures,  leads  us  to  be- 
lieve that  the  total  number  of  follicles  in  an  ovary  must  be  reckoned 
by  thousands. 

Development  of  the  Graafian  Follicles  and  Ova. — Having  described 
the  minute  anatomy  of  the  ovary,  we  are  now  prepared  to  consider 
the  manner  in  which  the  follicles  and  their  contained  ova  are  formed. 
The  germ  epithelium,  which  forms  the  superficial  layer  of  the  fetal 
ovary,  undergoes  rapid  multiplication,  as  a  result  of  which  the  cells 
grow  in  a  direction  toward  the  vascular  stroma  of  the  ovary ;  this 
likewise  increases,  and  in  a  direction  toward  the  germ  epithelium. 
The  stroma,  developing  between  these  masses  of  cells,  which  are  off- 
shoots from  the  germ  epithelium,  thus  isolates  them,  forming  islands 
or  nests.  These  nests  are  larger  below  than  above  where  they  are 
for  a  considerable  time  still  connected  with  the  superficial  germ  epi- 
thelium. Indeed,  at  birth  this  connection  exists  and  forms  what 
Pfliiger  has  denominated  the  ovarial  tubes.  The  cells  composing 
these  nests  multij^ly  themselves  by  the  process  of  karyokinesis,  thus 
increasing  the  size  of  the  nests,  and  forming  new  ones  by  being  con- 
stricted off  from  the  old  ones.  Some  of  the  cells  of  the  germ  epi- 
thelium undergo  special  development  in  the  cell-body  and  nucleus. 


DISEASES  OF   THE   OVAEIES.  477 

and  become  ova,  which  are  spoken  of  as  primitive  ova.  The  germi- 
nal vesicle  is  formed  before  the  vitelliis  or  the  zona  pellucida ;  but 
whether  the  formation  of  the  germinal  spot  precedes  that  of  the 
germinal  vesicle  has  not  been  fully  decided  in  the  vertebrates. 
Kolhker  finds  this  to  be  the  order  in  the  development  of  the  ova  of 
intestinal  worms.  As  the  multiplication  of  the  cells  of  the  germ 
■epithelium  goes  on  as  already  described,  there  is  also  a  continually 
increasing  differentiation  of  these  cells  forming  the  primitive  ova. 
This  production  of  ova  takes  place  in  the  nests  as  well  as  in  the 
superficial  layer,  and,  as  a  result,  we  have  each  nest  containing  a 
number  of  ova,  and  ova  are  also  found  in  the  same  manner  in  the 
■ovarian  tubes.  The  membrana  granulosa  is  formed  of  the  cells  of 
"the  nests  and  tubes  which  do  not  take  part  in  the  formation  of  the 
ova.  If  a  nest  or  an  ovarial  tube  contains  several  ova,  each  ovum 
will  form  a  center,  around  which  will  be  aggregated  a  layer  of  cells, 
forming  a  membrana  granulosa,  and  by  the  ingrowth  of  the  stroma 
hetween  these  collections  the  Graafian  follicles  are  formed.  External 
to  the  membrana  granulosa  is  formed  the  membrana  propria,  and 
still  more  externally  the  fibrous  capsule  or  theca  f  ollicuh.  As  already 
stated,  two  or  even  three  ova  may  become  enveloped  in  a  single 
layer  of  cells,  and  thus  a  single  Graafian  follicle  be  formed  contain- 
ing two  or  three  ova.  The  ova  and  the  membrana  granulosa  are 
consequently  formed  from  the  germ  epithelium,  which,  as  has  been 
seen,  consist  of  cells  from  the  mesoblast.  The  membrana  -propria, 
the  theca  folliculi,  the  stroma,  and  the  vessels  are  produced  from  the 
fetal  stroma,  which  was  also  originally  an  outgrowth  of  the  meso- 
"blast.  Some  excellent  authorities,  among  whom  may  be  mentioned 
Pfliiger  and  Kolliker,  believe  that  Graafian  follicles  and  ova  are  pro- 
duced after  birth  ;  others  equally  reliable,  as  Bischoff  and  Waldeyer, 
deny  this. 

Ovulation. — The  function  of  the  ovaries  is  primary  in  the  process 
of  reproduction.  Their  physiological  activity  precedes  the  uterine 
functions,  and  continues,  as  a  rule,  until  the  menopause,  and  possibly 
after  it.  Hence  the  functions  of  the  other  sexual  organs  appear  to 
be  responsive  to  the  influence  of  the  ovaries. 

There  are,  however,  differences  of  opinion  concerning  this  matter. 
Observations  have  been  made  which  show  that  ovulation  and  men- 
struation occur  independently  of  each  other,  in  exceptional  cases  at 
least,  and  a  high  degree  of  importance  has  been  given  to  that  appar- 
ently independent  action ;  but  such  irregularities  are  the  exception, 
not  the  rule.  There  are  facts  in  abundance  to  prove  that,  when  the 
ovaries  are  absent  or  rudimentary  from  birth,  the  function  of  the 


478  DISEASES  OF  WOMEN. 

uterus  is  never  established,  and  the  removal  of  the  ovaries  after 
puberty  arrests  menstruation  in  the  majority  of  cases.  All  that  we 
know  regarding  the  influence  of  the  ovaries  upon  development  of 
the  individual,  and  the  exercise  of  the  sexual  functions  throughout 
the  reproductive  period  of  life,  points  to  the  conclusion  that  these 
organs  are  the  prime  movers  and  controlling  agencies,  to  speak  flg- 
uratively,  in  the  sexual  system.  The  simple  facts  that  ovulation  and 
menstruation  do  not  follow  each  other  in  consecutive  order  in  excep- 
tional cases,  and  that  the  two  functions  are  occasionally  performed 
independently  of  each  other,  do  not  affect  the  general  rule  in  physi- 
ology. Because  irregularities  occur  in  the  harmonious  action  of  the 
sexual  organs,  their  independence  need  not  be  doubted.  The  same 
natural  order  of  phenomena  is  observed  in  all  processes  of  the  human 
economy.  The  primary  action  of  an  organ  that  stands  at  the  head 
of  a  system  sets  all  the  subordinate  organs  in  functional  motion. 
Taking  food  is  the  first  step  in  the  great  process  of  nutrition,  and 
digestion  and  assimilation  follow  in  natural  physiological  order. 
There  are  occasional  irregularities  in  the  succession  of  the  processes 
of  nutrition,  as  when  gastric  juice  is  secreted  in  the  absence  of  food 
in  the  stomach  ;  but  such  events  are  exceptions  to  the  mle.  Certain 
impressions  made  upon  the  brain  are  followed  by  deflnite  mental 
phenomena,  but  the  brain  sometimes  fails  to  respond  to  impres- 
sions ;  and,  again,  it  occasionally  acts  independently  of  extrinsic 
excitants.  So,  also,  an  action  or  function  which  has  been  be- 
gun by  a  given  influence  may  continue  after  the  cause  which  pro- 
duced it  has  been  removed.  If  we  accept  the  idea  that  the  ovaries 
are  essential  to  the  very  existence  of  the  sexual  system,  and  that  their 
office  is  the  highest  and  the  first  in  the  order  of  events  which  col- 
lectively make  the  complete  process  of  production,  it  is  easy  to  under- 
stand that  their  absence  would  arrest  the  action  of  the  whole  system. 
They  are  paramount,  not  subordinate,  in  reproduction,  and  in  the 
maintenance  of  the  relationship  between  the  general  and  the  sexual 
systems  the  ovaries  are  undoubtedly  the  most  potential  agents.  The 
uterus  and  vagina  are  superadded  structures,  rendered  necessary  by 
a  more  complex  and  perfect  system  of  reproduction  in  the  higher 
species.  The  anatomical  and  physiological  value  of  the  ovaries  as 
factors  in  the  reproductive  system  suggests  an  equal  distinction  in 
their  association  with  the  general  system,  and  in  their  influence  upon 
it.     This  correlation  has  been  variously  estimated  by  authors. 

Dr.  Henry  Maudsley,  in  his  book  entitled  "  Body  and  Mind," 
says :  "  The  organic  system  has  most  certainly  an  essential  part  in 
the  constitution  and  the  functions  of  the  mind.    In  the  great  mental 


DISEASES   OF  THE  OVAKIES.  4Y9 

revolution,  caused  by  the  development  of  the  sexual  system  at  pu 
berty,  we  have  the  most  striking  example  of  the  intimate  and  essential 
sympathy  between  the  brain  as  a  mental  organ  and  other  organs  of 
the  body.  The  change  of  character  at  this  period  is  not  by  any 
means  hmited  to  the  appearance  of  the  sexual  feelings  and  tlieir 
sympathetic  ideas,  but,  when  traced  to  its  ultimate  reach,  will  be 
found  to  extend  to  the  highest  feelings  of  mankind,  social,  moral, 
and  even  rehgious.  In  its  lowest  sphere,  as  a  mere  animal  instinct, 
it  is  clear  that  the  sexual  appetite  forces  the  most  selfish  person  out 
of  the  little  circle  of  self -feeling  into  a  wider  feeling  of  family 
sympathy  and  a  rudimentary  moral  feeling.  The  consequence  is 
that,  when  an  individual  is  sexually  mutilated  at  an  early  age,  he  is 
emasculated  morally  as  well  as  physically.  It  has  been  affirmed  by 
some  philosophers  that  there  is  no  essential  difference  between  the 
mind  of  a  woman  and  that  of  a  man  ;  and  that,  if  a  girl  were  sub- 
jected to  the  same  education  as  a  boy,  she  would  resemble  him  in 
tastes,  feelings,  pursuits,  and  powers.  To  my  mind,  it  would  not 
be  one  whit  more  absurd  to  affirm  that  the  antlers  of  the  stag,  the 
human  beard,  and  the  cock's  comb  are  the  effects  of  education,  or 
that,  by  putting  a  girl  to  the  same  education  as  a  boy,  the  female 
generative  organs  might  be  transformed  into  male  organs.  The 
physical  and  mental  differences  between  the  sexes  intimate  them- 
selves very  early  in  life,  and  declare  themselves  most  distinctly  at 
puberty ;  they  are  connected  with  the  influence  of  the  organs  of 
generation." 

This  much  being  claimed  by  so  high  an  authority  for  the  influ- 
ence of  the  sexual  organs  upon  the  development  and  function  of  the 
brain  and  nervous  system,  I  may  inquire  how  far  the  ovaries  are  re- 
sponsible for  such  results.  Yirchow  and  others  have  stated  that  the 
ovaries  give  to  woman  all  her  characteristics  of  body  and  mind,  and 
I  accept  the  proposition  without  qualification,  feehng  sustained  in 
doing  so  by  the  fact  that,  when  the  ovaries  are  absent  or  defective 
from  birth,  the  characteristics  of  the  female  sex  are  never  fully  de- 
veloped. The  tendency  in  the  development  of  those  in  whom  the 
ovaries  are  congeuitally  absent  is  toward  the  masculine  type  of  the 
race.  I  have  seen  two  such  cases,  decidedly  masculine  in  their  phys- 
ical and  mental  attributes,  and  there  are  many  others  recorded  in 
our  literature.  There  are  some  authors,  however,  who  appear  to 
stand  in  opposition  to  what  is  here  claimed.  In  Dr.  GoodeU's  paper 
presented  to  the  Pennsylvania  State  Society,  he  says,  that  "  The 
physical  and  psychological  influence  of  the  ovaries  upon  woman  has 
been  greatly  overrated."     And  again  he  says.  "  In  the  popular  mind 


480  DISEASES  OP  WOMEN. 

a  woman  without  ovaries  is  no  woman."  He  then  ^ives  his  own 
views  wliich  are  that,  "  beyond  the  induction  of  sterility  and  the 
probable  absence  of  menstruation,  the  deprivation  of  the  ovaries 
after  puberty  does  not  change  the  character  of  the  woman,"  Bat- 
tey,  Hegar,  Wells,  and  Peaslee,  are  given  as  confirming  this  doc- 
trine. The  views  held  by  these  authors  are  based  upon  observations 
of  mature  women  from  whom  the  ovaries  have  been  removed.  This 
alone  is  not  a  trustworthy  source  of  information,  because  the  results 
obtained  up  to  the  present  time  appear  to  be  quite  variable.  For 
example,  Dr.  T.  G.  Thomas  had  one  patient  who  was  passive  in 
her  sexual  relations  before  her  ovaries  were  removed,  but  became 
aggressive  afterward.  On  the  other  hand,  Dr.  M.  A.  Fallen,  in  a 
paper  read  before  the  American  Medical  Association,  in  June  last, 
related  the  history  of  a  girl  who  was  promptly  and  comjjletely 
cured  of  "  hystero-epilepsy "  and  an  incontrollable  desire  for  self- 
pollution  by  Battey's  operation. 

It  is  true,  no  doubt,  that  an  individual  who  has  been  fully  devel- 
oped under  the  influence  of  the  ovaries,  will  continue  to  manifest  her 
former  attributes  of  body  and  mind  after  these  organs  are  removed, 
but  it  does  not  therefore  follow  that  the  ovaries  were  negative  in  the 
process  of  developing  and  maintaining  those  attributes.  One  who  has 
become  blind  in  middle  life  will  talk  familiarly  and  understandingly  of 
objects  impressed  upon  the  mind  through  the  sense  of  sight,  but  one 
born  blind  can  not  comprehend  the  beauties  of  a  landscape.  This 
abundantly  proves  that  mental  peculiarities  may  continue  after  the 
physical  influences  which  caused  them  have  been  removed.  Obser- 
vations made  from  the  opposite  standpoint  give  evidence  which 
leads  to  the  same  conclusions.  We  find  that,  if  the  ovaries  are  pres- 
ent in  a  given  individual,  she  will  manifest  the  physical  and  psy- 
chical peculiarities  of  womanhood,  although  all  the  other  sexual  or- 
gans may  be  absent.  Women,  well  developed  in  all  that  is  pecul- 
iar to  the  sex,  have  been  observed  in  whom  the  uterus  and  vagina 
were  defective,  but  I  have  neither  seen  nor  heard  of  any  such  per- 
fection of  organization  occurring  when  the  ovaries  were  absent. 
Perhaps  the  strongest  argument  on  this  point  is  the  fact  that  other 
parts  of  the  general  system,  when  modified  by  the  influence  of  the 
ovaries,  are  rendered  capable  of  performing  the  major  functions  of 
the  uterus,  as  is  illustrated  in  a  very  striking  manner  by  vicarious 
menstruation  and  abdominal  gestation. 

In  this  connection,  a  brief  reference  may  be  made  to  tlie  influ- 
ence of  the  nervous  system  in  controlling  the  functions  of  reproduc- 
tion.   The  full  discussion  of  this  question  involves  problems  in  phys- 


DISEASES  OF  THE  OVARIES.  481 

iology  which  have  not  been  solved,  and  are  therefore  beyond  the 
scope  of  this  work.  Whether  the  higher  nerve-centers  are  devel- 
oped to  serve  the  demands  of  the  nutritive  and  reproductive  organ- 
izations, and  whether  the  location  of  the  nerve-centers  which  preside 
over  sexual  phenomena  is  in  the  cerebellum  or  the  lumbo-sacral 
portion  of  the  spinal  cord,  are  questions  which  I  am  not  at  present 
able  to  answer.  It  is  sufficient  for  the  present  purpose  to  keep  in 
mind  that  the  sexual  organs  are  dependent  upon  the  general  nutri- 
tive system  for  organic  support,  and  that  they  stimulate,  depress,  or 
modify  nutrition  through  the  ganglionic  nerves  chiefly,  and  that  the 
portion  of  the  brain  which  presides  over  the  organic  functions  also 
dominates  the  reproductive  organs.  We  should  also  recognize  the 
fact  that  the  emotions  are  in  part  dependent  upon  the  sexual  organs 
for  their  development,  and  on  the  other  hand  that  the  sexual  organs 
are  largely  affected  by  the  emotions.  Metaphysicians  agree  in  stat- 
ing that  the  sexual  appetence,  which  owes  its  existence  almost  en- 
tirely to  the  ovaries,  leads  to  more  emotions  than  any  other  human 
tendency,  and  clinical  observations  afford  good  evidence  to  the  phy- 
sician, that  the  emotions  affect  the  functions  of  the  sexual  organs  in 
a  marked  degree.  Grief,  fear,  anger,  and  even  great  joy  are  capa- 
ble of  arresting  menstruation  and  probably  ovulation  also.  In  view 
of  this  great  potentiality  of  the  ovaries  in  developing  certain  capa- 
bilities of  the  brain  and  nervous  system  and  in  influencing  their 
functions,  it  is  evident  that,  in  order  to  maintain  harmonious  action 
of  the  whole  organization,  it  is  necessary  that  the  ovaries  shall  exist 
in  full  development  and  functional  activity.  On  the  other  hand, 
these  organs  which  are  essential  to  the  well-being  of  the  individual 
must,  when  diseased,  exercise  a  potent  influence  in  deranging  the 
brain  and  nervous  system. 

From  a  somewhat  extended  consideration  of  this  subject,  I  am 
satisfied  that  a  great  many  affections  of  the  brain  and  nervous  sys- 
tem are  due  to  disease  of  the  ovaries.  The  remote  effects  of  ovarian 
disease  have  been  observed  and  recorded  to  some  extent,  but  not  so 
fully,  I  presume,  as  they  might  be.  The  tendency  of  observers  has 
been  to  attribute  certain  mental  derangements  and  diseases  of  the 
nervous  system  to  the  sexual  organs  in  general  or  the  uterus  espe- 
cially. A  little  attention  to  some  of  the  known  defects  and  diseases 
of  the  ovaries  and  their  relations  to  diseases  of  the  brain  and  nerv- 
ous system  will,  I  think,  materially  change  that  phase  of  the  subject. 

Imperfect  development  of  the  ovaries  not  only  modifies  the  phys- 
ical peculiarities  of  the  individual,  but  also  retards  the  development 
of  the  higher  nerve-centers.  The  demands  of  the  sexual  organs  (es- 
82 


482  DISEASES  OF  WOMEN. 

peciallj  the  ovaries)  stimulate  the  brain  to  a  higher  development. 
A  very  large  part  of  the  brain  and  nerve  power  is  devoted  to  repro- 
duction, and  if  that  function  is  never  established  because  of  the  ab- 
sence of  the  ovaries,  the  brain  and  nervous  system  are  never  fully 
developed.  When  a  woman  is  deprived  of  the  sexual  organs  the 
nutritive  system  may  possibly  attain  a  normal  development,  but  the 
nervous  system  does  not — it  remains  upon  a  lower  plane.  There  is 
usually  mental  weakness  and  often  derangement  of  mind  among 
those  in  whom  the  ovaries  are  imperfectly  developed.  Among  six- 
teen young  single  women,  that  came  under  my  observation  in  the 
Insane  Asylum,  I  found  twelve  who  had  imperfectly  developed  sex- 
ual organs.  Some  of  them  had  never  menstruated  at  all,  and  others 
had  done  so  imperfectly.  The  history  of  these  cases  led  to  the  con- 
clusion that  the  defective  development  of  the  ovaries  was  an  impor- 
tant element  in  causing  insanity.  They  no  doubt  inherited  an  in- 
sane neurosis  or  diathesis,  but  the  absence  of  ovarian  iutluence, 
which  favors  a  higher  and  more  complete  development  of  the  nerve- 
centers,  acted  as  the  major-cause  in  producing  the  insanity.  This  is 
not  claimed  to  be  a  positively  correct  deduction,  but  there  is  cer- 
tainly strong  presumptive  evidence  that  such  was  the  case.  The 
mental  derangement  appeared  in  the  majority  of  them  at  or  about 
the  period  of  puberty.  There  was  nothing  in  the  size  or  develop- 
ment of  these  patients  to  indicate  any  marked  defect  in  the  nutri- 
tive system.  The  nervous  and  sexual  system  alone  were  deficient. 
They  appeared  to  have  passed  through  girlhood  in  a  normal  way 
(although  not  manifesting  a  high  order  of  mental  capacity)  until 
the  period  when  the  sexual  organs  should  have  begun  to  exercise 
their  influence  in  completing  the  higher  development  of  the  nerve- 
centers.  When  that  failed  to  take  place,  the  brain  became  deranged,, 
instead  of  assuming  new  activities.  Still  it  is  possible  that  the  im- 
perfectly developed  sexual  organs  resulted  from  inferior  general 
organizations  which  were  from  the  beginning  of  a  low  type,  and 
that  the  insanity  which  followed  was  due  to  transmitted  lesions,  and 
was  not  dependent  upon  the  sexual  organs  at  all.  However,  the 
facts  appear  to  favor  the  opposite  conclusion.  One  thing  is  certain 
regarding  this  subject :  there  is  enough  in  the  nature  of  the  cases 
mentioned  to  invite  further  investigation  in  oi'der  to  settle,  as  far  as 
possible,  the  relation  of  the  ovaries  to  insanity  and  other  diseases  of 
the  nervous  system  which  occur  at  puberty. 

As  the  period  of  pul)erty  approaches  a  considerable  number  of 
Graafian  follicles  (from  twelve  to  thirty)  enlarge,  the  largest  reach- 
ing a  diameter  of  half  an  inch.     In  the  early  stage  of  development. 


DISEASES  OF   THE   OVARIES.  483 

it  will  be  remembered,  the  smallest  follicles  were  found  in  the  corti- 
cal layer,  those  of  medium  size  in  the  middle  layer,  and  still  deeper, 
the  larger  follicles.  These  follicles  increase  in  size  by  the  produc- 
tion of  an  increased  amount  of  liquor  folliculi.  This  so  distends  the 
wall  of  the  follicle  as  to  cause  it  to  project  from  the  surface  of  the 
ovary,  and  to  become  thinner  and  thinner  until  finally  it  bursts,  dis- 
charging the  ovum  with  some  of  the  cells  of  the  membrana  granu- 
losa, especially  those  forming  the  cumulus  proligerus.  The  ovum 
passes  into  the  Fallopian  tube,  and  through  it  descends  to  the  uterus. 
This  ripening  and  discharge  of  ova  is  the  process  of  ovulation  and 
occurs  periodically,  in  the  human  female  about  every  four  weeks. 
As  the  time  approaches  in  each  month  for  the  rupture  of  a  follicle 
there  is  an  abundant  formation  of  vascular  loops  in  connection  with 
increased  growth  of  the  membrana  propria,  which  together  with 
the  liquor  folliculi  distends  the  wall  of  the  follicle.  This  distention 
stimulates  the  ovarian  nerves,  and  as  a  result  there  is  an  increased  flow 
of  blood  to  the  ovaries  and  other  organs  of  generation.  The  wall  of 
the  follicle,  in  addition  to  being  distended,  also  becomes  fatty  at  its 
most  projecting  part,  and  when  it  is  no  longer  able  to  withstand  the 
internal  pressure  it  bursts  and  the  ovum  is  discharged.  When  this 
rupture  takes  place  there  is  in  the  human  female  haemorrhage  from 
the  vessels  already  spoken  of  as  being  found  in  the  interior  of  the 
follicle.  The  amount  of  blood  effused  is  sufficient  to  fill  the  cavity 
of  the  follicle.  It  soon  coagulates,  the  serum  is  reabsorbed,  the 
haemoglobin  becomes  hsematoidin,  and  after  a  time  the  coloring-mat- 
ter disappears.  In  short,  the  same  changes,  take  place  in  the  blood 
here  as  when  a  haemorrhage  occurs  elsewhere  in  a  closed  cavity. 
The  wall  of  the  follicle  becomes  hypertrophied  and  convoluted,  and 
later  on  undergoes  fatty  degeneration,  with  the  formation  of  lutein, 
giving  to  the  structure  a  yellow  color,  on  which  account  it  has  been 
called  a  corpus  luteum.  The  corpus  luteum  spurium  by  which 
name  the  coi-pus  luteum  of  menstruation  is  known,  reaches  its  maxi- 
mum of  development  at  the  end  of  the  third  week  after  menstrua- 
tion, at  which  time  it  commences  to  diminish  in  size  until  at  the 
end  of  the  eighth  week  it  is  reduced  to  an  insignificant  yellowish 
cicatrix  about  one  fourth  of  an  inch  in  diameter,  but  it  sometimes 
may  be  discovered  if  carefully  sought  at  the  end  of  eight  months. 
If,  however,  the  ovum  which  escaped  from  a  given  Graafian  follicle 
becomes  impregnated,  then  the  process  becomes  modified  in  that  fol- 
licle. The  corpus  luteum  is  then  denominated  veram  instead  of 
spurium.  The  differences  between  the  two  vaneties  of  coi-pora 
lutea  are  of  degree  not  of  kind.     The  changes  which  take  place  are 


484  DISEASES  OF  WOMEN. 

the  same  in  both  up  to  the  end  of  the  third  week,  then,  instead  of 
diminishing,  the  corpus  luteum  verum  continues  to  grow  until  the 
end  of  the  fourth  month  when  it  reaches  the  height  of  its  develop- 
ment. It  retains  this  maximum  until  the  beginning  of  the  seventh 
month  when  it  commences  to  diminish,  but  may  sometimes  still  be 
discovered  nine  months  after  delivery.  The  history  of  the  corpus 
luteum  is  admirably  described  by  Dalton  to  whose  work  on  human 
physiology  the  reader  is  referred  for  a  detailed  account  of  its  forma- 
tion, and  the  subsequent  changes  which  it  undergoes. 

LESIONS  OF   FORMATION  OF  THE  OVARIES. 

Both  ovaries  may  be  entirely  absent,  or,  perhaps,  it  would  be 
more  correct  to  say,  entirely  rudimentary,  or  one  may  exist  alone,  or 
there  may  be  a  third  one  present.  When  a  single  ovary  is  absent 
the  condition  of  uterus  unicornis  usually  exists,  although  this  mal- 
formation of  the  uterus  is  not  necessarily  accompanied  by  an  absence 
of  either  ovary. 

The  absence  of  an  ovary  may  be  accounted  for  in  different  ways ; 
it  may  not  have  been  developed,  it  may  have  been  properly  formed, 
and  by  some  dislocation  of  the  uterus  have  had  its  circulation  and 
nutrition  so  interfered  with  as  to  have  caused  it  to  shrivel  and  be- 
come absorbed,  or  it  may  have  become  attached  to  some  other  ab- 
dominal organ,  and  then  its  absence  be  only  apparent  and  not  real. 

Several  cases  are  on  record  in  which  a  third  ovary  has  been 
found.  The  most  interesting  of  these  is  one  which  is  described  and 
figured  by  Winckel  in  his  work  on  "  Diseases  of  Women."  In 
most  of  the  instances  the  supernumerary  ovary  was  found  near  one 
or  the  other  of  the  normal  ovaries,  and  either  behind  or  in  the  broad 
ligament.  In  Winckel's  case  it  was  situated  in  front  of  the  uterus 
and  connected  ^vith  the  posterior  wall  of  the  bladder. 

As  Winckel  has  so  well  pointed  out,  these  cases  of  supernumer- 
ary ovaries  are  always  to  be  borne  in  mind  in  making  a  diagnosis. 
A  cyst  forming  in  the  third  ovary  as  found  in  his  case  might  be  de- 
tected between  the  bladder  and  the  uterus,  and  be  mistaken  for 
some  other  form  of  tumor.  In  such  cases  also  the  removal  of  two 
ovaries  may  not  prevent  conception,  the  third  ovary  being  in  all  re- 
spects normal,  and  consequently  able  to  discharge  ova.  So  also  even 
after  two  ovaries  are  removed,  should  a  tliird  exist  a  cystoma  may 
form,  which  will  require  operative  interference. 


CHAPTER  XXYI. 

DISEASES    OF   THE   OVARIES.      (CONTINUED.) 

HYPERiEMIA,    ACUTE    AND    CHRONIC    OVARITIS    AND    PRO- 
LAPSUS  OF  THE  OVARIES. 

Inflammatioii  of  the  Ovaries. — There  are  two  forms  of  inflamma- 
tion of  the  ovaries,  the  acute  and  the  chronic.  These  are  very  dis- 
tinctly different  so  far  as  their  clinical  history  is  concerned.  There 
is  another  affection  closely  allied  to  these  which  is  described  by  some 
writers  as  hypersemia.  All  these  are,  however,  but  different  degrees 
of  the  same  affection,  though  each  follows  a  different  course  and 
gives  a  history  pecuhar  to  itself.  This  latter  fact  justifies  the  con- 
sideration of  the  acute  and  chronic  forms,  at  least,  of  ovaritis  as  sepa- 
rate affections.  The  third  form,  hypersemia,  is  not  so  fully  under- 
stood nor  does  it  stand  out  so  distinctly  from  the  chronic  form  as  to 
make  its  description  easy. 

Ovarian  Hyperaemia. — While  many  of  the  characteristics  of  ova- 
rian hj^jersemia  are  like  those  of  ovaritis,  there  is  very  good  reason 
based  upon  clinical  evidence,  to  believe  that  the  two  are  different 
both  in  pathology  and  clinical  history. 

Ovarian  hyperiemia,  as  it  is  generally  observed,  resembles  many 
of  the  so-called  functional  diseases  of  the  ovary,  in  that  there  is  de- 
rangement of  function,  with  symptoms  of  organic  disease  which 
usually  disappear,  leaving  no  evidence  that  there  has  ever  been  any 
change  of  structure  or  any  products  of  inflammation.  All  this  dem- 
onstrates that  the  pathology  is,  as  the  name  implies,  a  derangement 
of  circulation  in  which  there  is  congestion,  and  the  consequent  de- 
rangement of  function  with  the  accompanying  or  resulting  pain  and 
suffering.  The  hypersemia  usually  affects  both  ovaries,  and,  as  a 
rule,  extends  to  the  other  pelvic  organs,  after  a  time,  at  least.  The 
derangement  of  function  also  extends  to  the  uterus  giving  rise  to 
derangement  of  menstruation.     In   fact,  the  congestion  and  func- 

4S5 


486  DISEASES  OF  WOMEN. 

tional  derangements  of  the  uterus  are  secondary  to  the  ovarian 
hyperaemia.  There  is  much  in  regard  to  pathology  of  this  affection 
which  is  inferred  from  the  symptoms,  and  can  not  be  demonstrated 
by  post-mortem  investigation.  The  congestion  may  be  of  long  or 
of  short  duration,  its  continuance  depending  upon  the  persistence 
of  the  causes  which  give  rise  to  it.  If  it  is  well-marked  and  long- 
continued,  it  tends  to  chronic  ovaritis,  and,  perhaps,  to  degeneration 
of  the  ovaries  and  premature  atrophy.  Should  the  causes  which  pro- 
duce the  congestion  continue  active  and  no  treatment  be  employed, 
the  affection  may  continue  indefinitely.  The  general  health  be- 
comes undermined  by  the  derangement  of  the  menstrual  function 
and  the  exhaustion  of  the  nervous  system ;  and  if  the  patient  is  not 
relieved  by  treatment  or  by  improved  hygienic  conditions,  she  con- 
tinues a  sufferer  until  the  menopause. 

With  so  little  that  is  definite  regarding  the  pathology,  one  might 
well  ask  if  the  fact  is  yet  established  that  there  is  a  distinct  affection 
to  be  known  as  ovarian  hyperaemia.  In  answer  to  this,  it  can  only 
be  said  that  the  clinical  history  clearly  points  to  this  derangement  of 
the  circulation  as  the  only  rational  explanation  of  the  phenomena 
presented  in  these  cases.  It  should  be  stated  here  that  there  neces- 
sarily must  be  ])resent  in  this  affection  a  derangement  of  ovarian  in- 
nervation as  well  as  hyperaemia.  In  fact,  it  appears  that  this  de- 
rangement is  the  starting-point  in  the  morbid  condition.  This 
view  of  the  matter  is  favored  l)y  the  affection  depending  for  its 
origin  upon  perversion  of  the  emotions  in  those  of  nervous  tempera- 
ment. 

Symptomatology. — Hyperaemia  of  the  ovaries  occurs  most  fre- 
quently among  those  who  are  unmarried,  or  among  young  widows 
who  have  never  had  children. 

It  does  not  come  on  abruptly  like  an  attack  of  acute  ovaritis,  as 
a  rule,  though  it  occasionally  does  so,  but  is  developed  rather  gradu- 
ally. Those  most  liable  to  this  affection  are  the  nervous  and  emo- 
tional wlio  live  in  conditions  of  life  favoring  excitation  without 
complete  functional  action  of  the  sexual  organs.  I  have  never  seen 
a  case  of  this  kind  among  those  who  lived  under  wholesome  con- 
ditions of  life  or  who  were  married,  l)earing  and  nursing  children, 
and  who  lived  quiet,  rational  lives.  At  the  beginning  there  are 
pain  and  heaviness  in  the  region  of  the  ovaries,  usually  accom- 
panied by  much  nervous  disturbance  of  the  nature  of  irritability  and 
weakness,  the  patient  being  easily  excited  and  as  easily  fatigued. 
Soon  after  the  appearance  of  these  symptoms  the  menstrual  func- 
tion becomes  deranged.     There  is   usually  menorrhagia,  which  is 


DISEASES  OP  THE   OVARIES.  487 

preceded  by  increase  of  the  ovarian  pain.  Sometimes  tlie  pain  is 
relieved  and  the  patient  feels  much  better  during  the  menstrual 
flow,  and  for  a  time  after  it  ceases.  In  some  cases  the  first  symp- 
tom developed  is  derangement  of  the  menstrual  function,  gener- 
ally too  frequent,  and  too  free  menstruation.  In  a  word,  menorrhagia 
is  the  most  prominent  symptom  of  ovarian  hypersemia.  The  free 
flow  being  due  originally  to  the  ovarian  excitation  is  conservative 
at  first,  I  believe,  reheving  the  congestion  which  produced  it.  I 
have  frequently  seen  young  women,  who  apparently  suffered  from 
ovarian  congestion,  recover  completely  after  one  or  more  free  at- 
tacks of  menorrhagia.  When  the  excessive  menstruation  does  not 
relieve  the  congestion,  which  it  certainly  will  not  do  if  the  causes 
which  produced  it  are  continued,  then  it  leads  to  anaemia  and  neu- 
rasthenia, and  this  state  of  health  may  continue  indefinitely. 

There  are  other  symptoms  which  may  be  mentioned,  as  backache 
and  general  pelvic  tenesmus,  increased  on  walking  sometimes,  but 
not  always.  In  the  less  severe  forms  of  hypersemia  of  not  very 
long  standing,  active  muscular  exercise  gives  relief  not  for  the  time 
only,  but  is  oftentimes  permanently  beneficial.  There  is  often  irri- 
tability of  the  bladder,  which  is  purely  nervous. 

Physical  Signs. — There  is  tenderness  on  deep  pressure  made  in 
the  iliac  regions,  not  acute,  but  of  that  dull  character  which  is  pecul- 
iar to  the  ovaries.  As  the  disease  affects  both  ovaries,  as  a  rule, 
there  is  tenderness  alike  on  both  sides. 

Bimanual  examination  usually  shows  tenderness  better  than  al> 
dominal  pressm:'e,  but  I  have  found  that  in  these  cases  it  is  very  diffi- 
cult to  grasp  the  ovaries  between  the  two  hands,  owing  to  the  fact 
that  the  abdominal  muscles  are  tense ;  while  in  the  majority  of  cases 
there  is  tenderness  if  pressure  is  made  upon  the  ovaries,  either 
through  the  vaginal  or  abdominal  walls,  I  have  seen  many  cases  in 
which  steady  but  not  too  heavy  pressure  in  the  iliac  regions  gave  re- 
lief. Perhaps  these  were  cases  of  the  kind  that  Charcot  calls  hys- 
tero-epilepsy,  in  which  the  convulsions  are  reheved  by  pressure  upon 
the  ovaries.  I  have  seen  some  of  Charcot's  cases,  and  believe  them 
to  be  ovarian  hypersemia. 

The  physical  signs  obtained  are  rather  negative,  but  by  excluding 
the  evidence  of  other  ovarian  affections,  and  taking  the  history  into 
account  a  presumptive  diagnosis  can  be  made,  and  the  diagnosis  will 
be  confirmed  by  the  subsequent  history.  Under  treatment  and  im- 
proved moral  and  physical  hygiene,  recovery  will  take  place  much 
m.ore  promptly  and  completely  than  in  chronic  inflammation. 

In  connection  with  this  affection  of  the  ovaries,  especially  if  it 


488  DISEASES  OF  WOMEN. 

has  existed  for  several  montlis,  there  is  usually  congestion  of  the 
uterus  and  vagina  which  yields  promptly  to  treatment. 

Prognosis. — The  great  majority  of  patients  recover  under  appro- 
priate treatment.  In  fact,  many  of  them  recover  after  the  causes 
are  removed  without  any  treatment  whatever.  This  will  be  seen  in 
the  history  of  the  cases  given  further  on. 

Causation. — Overstimulation  of  the  emotions  in  those  of  a  nerv- 
ous temperament  is  one  of  the  chief  causes  of  ovarian  congestion. 
This  is  operative  among  those  who  are  not  usefully  employed,  but 
are  permitted  or  even  encouraged  to  turn  their  attention  to  the 
procreative  function  while  they  are  still  undergoing  development. 
Stimulating  tonics  which  create  an  appetite  which  is  not  satisfied 
with  food  will  cause  gastric  congestion,  and  all  the  consequences 
which  arise  therefrom.  In  like  manner  stimulating  the  sexual 
appetence  of  unoccupied  emotional  young  girls  by  evil  influ- 
ences or  improper  associations  leads  to  ovarian  congestion.  Those 
who  have  lived  in  the  proper  exercise  of  the  sexual  function,  but 
have  been  abruptly  cut  off  from  normal  gratification,  are  prone  to 
ovarian  congestion.  Indulgence  beyond  normal  gratification  is  also 
said  to  have  produced  the  same  result.  All  these  causes  are,  to  a 
great  extent,  psychical,  but  ovarian  congestion  may  be  produced  by 
purely  physical  causes.  It  may  be  secondary  to  endometritis,  seden- 
tary habits,  and  constipation,  which  may  interrupt  the  free  circula- 
tion in  the  pelvic  organs. 

It  is  rare,  however,  that  cases  of  ovarian  congestion  can  be  traced 
to  such  causes. 

Treatment. — The  removal  of  the  cause,  when  that  can  be  accom- 
plished, is,  as  I  have  already  said,  often  suificient  to  give  relief. 
The  termination  of  an  engagement  in  marriage  has  cured  the  men- 
orrhagia  in  many  cases,  and  complete  recovery  has  followed  when 
pregnancy  occurred. 

A  like  benefit  has  been  brought  about  in  younger  patients  by 
directing  the  attention  to  something  other  than  self  and  the  feelings 
and  emotions.  A  change  from  books  and  society  to  the  woods  and 
fields,  and  outdoor  occupation  in  the  way  of  amusements  should  be 
employed.  Bathing  is  useful — either  sea-bathing  or  the  shower-bath 
— if  the  patient  is  strong  enough  to  bear  it.  Tonics  to  restore  the 
general  strength,  nux-vomica  being  the  most  efiicient ;  counter-irri- 
tants, ergot  and  bromides  complete  the  list  of  therapeutic  agents. 

The  tonic  and  ergot  should  be  given  through  the  day,  and  the 
bromide  at  night  to  secure  rest  and  sleep. 

Acute  Ovaritis. — This  is  quite  distinct  from  other  ovarian  affec- 


DISEASES  OF   THE  OVARIES.  489 

tions,  because  it  is  probably  always  the  result  of  some  special  cause 
— usually  a  specific  poison,  such  as  gonorrhceal  infection,  puerperal 
septicaemia,  or  some  constitutional  condition  like  that  which  exists 
in  the  eruptive  fevers  and  in  acute  rheumatism.  It  may  also  be 
traumatic,  though  that  is  rare,  except  when  the  ovaries  become  in- 
volved in  a  general  pelvic  inflammation  due  to  an  injury.  There 
has  been  and  still  is  much  confusion  of  thought  regarding  the  pa- 
thology of  ovaritis.  Some  of  the  conflicting  accounts  arise,  I 
presume,  from  confounding  acute  and  chronic  ovaritis  and  ovarian 
hypersemia.  There  is,  no  doubt,  so  marked  a  resemblance  between 
these  three  affections,  and  they  are  so  often  associated  that  it  is  im- 
possible to  differentiate  them  in  many  instances.  Still,  between  the 
typical  causes  of  each,  met  occasionally  in  practice,  the  distinction 
can  be  easily  made.  The  acute  affection  runs  its  course  rapidly,  and 
terminates  either  in  death  or  a  subsidence  of  the  acute  inflammatory 
symptoms  and  a  damaged  state  of  the  ovaries.  There  are  well-detined 
symptomatic  forms,  and  the  changes  of  structure  which  result  in 
connection  with  the  clinical  history  are  such  as  belong  to  acute 
inflammatory  action.  In  chronic  ovaritis  there  are,  on  the  con- 
trary, changes  which  take  place  much  more  slowly,  and  are  not 
marked  by  the  same  definite  products  of  inflammation.  In  conges- 
tion of  the  ovaries  there  are  no  tissue  changes.  It  appears  to  me 
that  acute  and  chronic  ovaritis  are  as  well  deflned,  both  in  clinical 
history  and  anatomical  changes,  as  acute  and  chronic  nephritis. 
There  is  still  much  need  of  more  observation  and  careful  comparisons 
of  the  clinical  history  and  post-mortem  appearances  in  order  to  settle 
more  definitely  the  pathology  of  acute  ovaritis. 

Pathology. — When  ovaritis  occurs  in  connection  with  the  puer- 
peral state,  only  one  ovary  is  affected  as  a  rule.  All  the  tissues  of 
the  ovary  take  part  in  the  congestion,  which  is  the  first  morbid 
change  produced.  Following  the  congestion  there  is  swelling  from 
the  transudation  of  serum,  which  is  often  of  a  reddish  color.  The 
inflammation  involves  all  the  tissues  ;  the  vesicles,  stroma,  parenchy- 
ma, and  the  envelope,  and  not  infrequently  the  fimbriated  extremity 
of  the  Fallopian  tube  is  involved,  and  the  peritonseura  around  the 
ovary.  Then  the  ovary  becomes  surrounded  with  the  exudate,  so 
that  from  the  gross  appearances  it  is  not  possible  to  tell  whether  the 
ovary  or  the  peritonaeum  was  first  attacked.  The  changes  in  the 
ovary  are,  in  addition  to  general  serous  effusion,  destruction  of  the 
vesicles  from  effusion  or  purulent  infiltration ;  sometimes  one  large 
abscess  is  formed  in  the  ovary  which  destroys  most  of  the  tissues ; 
in  other  cases  a  number  of  small  abscesses  are  found.     In  short, 


490  DISEASES  OF  WOMEN. 

acute  ovaritis  is  general  as  a  rule,  but  occasionally  partial  ovaritis 
occurs.  From  what  lias  been  said,  it  -wall  appear  that  ovarian  inflam- 
mation is,  in  its  morbid  anatomy,  similar  to  adenitis  generally.  The 
congestion,  serous  effusion,  suppuration,  the  formation  of  single  or 
multiple  abscess,  and  plastic  exudations  on  the  free  surface  of  the 
ovary  are  the  usual  changes.  These  changes  are  manifested  in  dif- 
ferent degrees  at  various  parts  of  the  ovary,  due  in  part  to  the  course 
which  the  disease  follows,  but  more  especially  to  the  different  struct- 
ures or  elements  which  compose  the  ovary.  In  addition  to  these 
pathological  changes,  there  are  others  which  may  or  may  not  occur. 
There  are  prolapsus  of  the  ovary  and  adhesions  to  neighboring  organs. 
The  abscess  may  open  into  the  rectum  or  the  peritoneal  cavity,  or 
find  its  way  into  the  lymphatics  or  veins,  which  are  often  dilated ; 
quite  frequently  the  abscess  does  not  discharge  at  all,  but  remains 
encysted. 

Sijinptomatology. — There  are  both  local  and  constitutional  symp- 
toms in  acute  ovaritis.  There  may  be  a  chill  or  rigor,  followed  by 
fever,  nausea,  vomiting,  and  pain  more  or  less  acute.  The  acuteness 
of  the  pain  appears  to  be  greatest  when  the  peritonaeum  is  affected. 
There  is  marked  disturbance  of  the  nervous  system,  shown  by  iri'i- 
tability  and  anxiety,  but  no  delirium ;  not  infrequently,  however, 
hysteria  and,  in  a  few  cases,  mania  have  been  developed. 

The  only  difference  which  I  have  noticed  between  the  symp- 
tomatic form  of  ovaritis  and  other  acute  pelvic  inflammation  is  that 
in  the  former  the  nervous  symptoms  are  more  marked.  In  mild 
forms  of  this  affection  the  constitutional  disturbances  are  less  severe  ; 
still  there  is  an  elevation  in  the  temperature,  increased  frequency 
of  the  pulse,  and  deranged  primary  nutrition.  The  appetite  is  poor, 
and  there  are  dyspepsia,  flatulence,  and  constipation.  The  symp- 
tomatic form  subsides  to  some  extent  after  the  first  few  days,  and 
the  formation  of  pus  reawakens  the  general  disturbances.  There 
may  be  a  chill,  followed  by  perspiration,  or  irregular  rigors  may 
occur,  and  the  pain  may  return  more  acutely.  The  local  symptom 
is  pain,  which  is  often  circumscribed,  the  patient  being  able  to  point 
out  the  exact  spot  in  the  iliac  fossa  where  the  pain  starts,  and  from 
which  it  radiates,  and  where  the  tenderness  is  felt  on  pressure.  Tliere 
are  pelvic  tenesmus,  and  a  frequent  desire  to  urinate,  and,  if  the  left 
ovary  is  the  one  affected,  there  is  often  excruciating  pain  during 
defecation. 

Physical  Signs. — There  is  acute  tenderness  on  pressure,  more 
definitely  located  than  in  pelvic  peritonitis.  Sometimes  the  ovary 
can  be  felt  through  the  abdominal  walls.    This  is  frequently  the  case 


DISEASES  OF  THE   OVARIES.  491 

when  the  ovary  is  greatly  enlarged  by  the  products  of  the  inflam- 
mation, and  is  fixed  high  up  by  adhesions.  By  the  vaginal  touch 
heat  and  tenderness  are  detected.  Pressure  causes  pain  of  a  char- 
acter peculiar  to  the  ovary.  The  finger  should  be  carried  high  up 
behind  the  uterus,  when  the  ovary  may  be  caught  between  it  and 
the  sacrum.  By  very  gentle  manipulation  the  uterus  and  the 
ovary  also,  perhaps,  are  found  to  be  movable  to  a  limited  degree. 
The  location  of  the  tumor,  its  partial  mobility,  its  form,  and 
that  it  is  not  connected  directly  to  the  uterus,  all  go  to  aid  in 
making  the  diagnosis.  The  rectal  touch  will  enable  the  examiner 
to  locate  it. 

Differentiation. — Owing  to  the  fact  that,  in  the  present  state  of 
science  regarding  this  affection,  the  diagnosis  is  not  at  all  times  easy 
to  make,  it  is  necessary  to  mention  the  conditions  which  resemble  it, 
and  point  out  the  differences  which  helj)  to  define  and  distinguish 
acute  ovaritis  from  them.  Acute  ovaritis  is  easily  distinguished 
from  chronic  ovaritis  and  hypersemia  by  the  absence  in  the  latter 
of  symptomatic  fever.  Much  aid  is  obtained  by  the  history  which 
nearly  always  presents  some  of  the  causes  which  give  rise  to  acute 
ovaritis. 

It  may  be  distinguished  from  pelvic  peritonitis  and  cellulitis  by 
the  physical  signs.  The  fixation  of  the  uterus  and  the  more  diffuse 
distribution  of  the  inflammatory  products  being  most  marked  in  the 
cellular  and  peritoneal  inflammation.  In  cases  of  acute  ovaritis  that 
are  complicated  with  cellulitis  or  peritonitis,  the  differential  diag- 
nosis can  not  be  made  upon  the  living  subject.  That  these  affections 
have  occurred  together  can  be  determined,  but  which  was  the  pri- 
mary affection  can  only  be  surmised  from  the  history. 

Prognosis. — When  suppuration  occurs,  and  the  abscess  opens 
Into  the  peritoneal  cavity,  a  fatal  termination  should  be  expected. 
Death  may  also  occur  from  septicseraia  when  the  contents  of  the  sac 
of  the  abscess  find  their  wa}^  into  the  lymphatics  or  veins.  This, 
I  believe,  is  more  likely  to  occur  when  there  are  a  number  of  small 
abscesses  with  thin  walls.  If  the  accumulated  pus  is  discharged 
through  the  rectum  or  vagina,  or  if  the  abscess  becomes  encysted, 
recovery  may  take  place.  The  ovary  is,  of  course,  damaged  or  de- 
stroyed, but,  if  one  ovary  is  left  in  a  normal  state,  the  patient  may 
regain  health  and  bear  children.  In  some  cases  of  chronic  suppura- 
tion, in  cases  where  the  pus  is  discharged  through  the  rectum  or 
vagina,  or  is  walled  in  by  peritoneal  adhesions  from  plastic  exuda- 
tion, relief  may  be  obtained  by  surgical  means  to  be  referred  to 
when  discussing  the  treatment. 


492  DISEASES  OF   WOMEN. 

Causation, — The  causes  of  acute  ovaritis  have  abeady  been 
named. 

Puerperal  septic  absorption  and  gouorrhoeal  infection  are  the 
chief  causes.  Lawson  Tait  has  called  attention  to  the  eruptive  fevers 
and  acute  rheumatism  as  giving  rise  to  acute  ovai'itis,  and  my  own 
observations  agree  with  his  in  the  main. 

While  I  have  not  seen  ovaritis  occurring  in  connection  with  rheu- 
matism, I  have  seen  several  cases  caused  apparently  by  the  eruptive 
fevers.  I  have  never  seen  ovaritis  due  to  traumatic  causes,  still  I 
can  believe  that  such  might  be  the  case. 

Treatment. — In  regard  to  the  management  of  acute  ovaritis,  I 
may  say,  in  brief,  th^t  the  cases  that  have  come  under  my  care  have 
been  treated  exactly  as  I  have  treated  pelvic  peritonitis  or  cellulitis. 
I  have  not  discovered  any  special  line  of  management  as  specific 
medication  ;  hence,  to  avoid  useless  repetition,  I  must  refer  the  reader 
to  the  treatment  of  the  aliove-named  affections.  1  may  remark  in 
passing  that,  knowing  that  the  causes  are  specific  in  the  majority  of 
cases,  care  may  be  taken  to  prevent  the  occurrence  of  ovaritis  by 
judicious  treatment  of  the  affections  which  give  rise  to  it.  There 
is  room  for  doubt,  however,  if  much  can  be  accomplished  in  this 
way. 

Chronic  Ovaritis. — Pathology. — The  study  of  the  pathology  of 
ovaritis  derives  a  special  interest  from  the  fact  that  the  ovary  differs 
from  all  other  organs  of  the  body,  in  that  its  function  is  performed 
at  the  expense  of  a  portion  of  its  structure  which  is  never  restored 
to  its  original  condition.  The  rupture  of  each  Graafian  vesicle  in 
ovulation  causes  the  destruction  of  the  vesicle.  Rudimentary  vesi- 
cles mature  and  repeat  the  function  of  their  predecessors,  and  are  in 
turn  destroyed.  Finally,  the  supply  ceases,  and  the  ovary,  worn  out 
in  structure,  Ijecomes  functionally  incompetent  long  before  the  gen- 
eral organization  has  reached  the  end  of  its  life  and  activity.  In  all 
other  organs  of  the  body  function  is  effected  tljrough  cellular  disin- 
tegration and  restoration. 

This  peculiarity  in  the  natural  history  of  the  ovary  makes  it  dif- 
ficult for  the  superficial  observer  to  distinguish  between  the  normal 
degeneration  and  the  structural  changes  which  result  from  chronic 
ovaritis.  Experts  also  find  it  no  easy  matter  to  distinguish,  by  gross 
appearances,  the  atrophy  of  old  age  from  the  cirrhosis  of  inflamma- 
tion. 

The  patholc>gy  of  ovaritis  is  characterized  by  changes  of  struct- 
ure brought  about  chiefly  by  areolar  hyperplasia  flrst,  then  by  atro- 
phy of  the  normal  tissues,  and  finally  by  a  condition  of  cirrhosis. 


DISEASES  OF  THE  OVARIES.  493 

In  this  respect  the  morbid  process  and  its  products  more  resem- 
ble degeneration  than  inflammation  such  as  is  observed  in  other 
organs.  In  the  natural  history  of  its  pathology  chronic  ovaritis  is 
more  like  certain  forms  of  chronic  nephritis.  Owing  to  these 
peculiar  and  distinguishing  features,  the  affection  has  little  in  com- 
mon with  acute  puerperal  or  non-puerperal  ovaritis,  or  with  sec- 
ondary acute  ovaritis  due  to  peritonitis,  and  therefore  all  such 
conditions  will  be  carefully  excluded  from  the  discussion  of  the 
subject  in  hand. 

The  first  variation  from  the  normal  toward  the  pathological  is 
deranged  innervation ;  the  ovary,  owing  to  its  important  ofiice  and 
intimate  relations  to  the  other  organs,  being  peculiarly  prone  to  re- 
flex disturbances.  These,  though  temporary  as  a  rule,  when  oft  re- 
peated and  prolonged  in  duration,  induce  changes  in  the  circulation 
which  impair  nutrition  and  finally  produce  changes  of  structure. 
This  ovarian  hypersemia,  the  first  step  in  the  process,  may  subside, 
and  complete  recovery  follow.  Reliable  evidence  of  this  has  been 
obtained,  first  by  clinical  observation  of  cases  which  have  given  all 
the  signs  and  symptoms  of  ovarian  congestion,  and  which,  under 
careful  management,  have  completely  recovered. 

Secondly,  by  inspection  after  laparotomy.  I  have  not  infre- 
quently found  a  prolapsed,  tender,  and  painful  ovary,  which  upon 
inspection  was  markedly  hypersemic,  but  presented  no  apparent 
change  of  structure  except  oedema.  After  fixing  it  in  place  by 
stitching  the  utero-ovarian  ligament  to  the  upper  border  of  the  broad 
ligament,  the  signs  and  symptoms  have  all  subsided.  The  continu- 
ation of  the  hypersemia  slowly  produces  those  structural  changes 
which  are  invariably  effected  by  prolonged  mal-nutrition.  The  first 
noticeable  changes  take  place  in  the  blood-vessels  themselves.  They 
become  dilated,  and  a  peculiar  degeneration  of  their  walls  occurs. 
These  changes  have  been  elaborately  studied  by  Dr.  E.  Xoeggerath, 
who  advanced  the  idea  that  these  vascular  changes  were  closely  re- 
lated to  the  genesis  of  ovarian  cystomata.  This  may  be  true  in  cer- 
tain cases,  but  it  more  frequently  ends  in  areolar  hyperplasia  of  the 
stroma,  which  gradually  goes  on,  and  in  time  crowds  out  all  the  nor- 
mal structural  elements  of  the  ovary.  Finally,  a  true  cirrhosis  is 
produced.  With  these  changes  in  the  blood-vessels  the  circulation 
is  interrupted  to  a  degree  that  causes  oedema,  which  increases  the 
size  of  the  ovary  and  renders  it  softer.  Apoplexies  sometimes  oc- 
cur, and  occasionally  one  or  more  of  the  blood-clots  may  be  seen 
near  the  surface.  These  conditions  can  be  distinguished  from  a  dis- 
eased vesicle  by  the  staining  of  the  tissues  around  the  clot.     This 


494  DISEASES  OF   WOMEN. 

last-mentioned  lesion  oecnrs  in  the  early  stage  of  the  ovaritis,  and 
gradually  disappears  as  the  process  of  hyperplasia  proceeds  to  a. 
complete  cirrhosis.  These  changes  explain  some  of  the  important 
facts  in  the  clinical  history.  The  ovary  which  is  found  enlarged, 
softened,  and  tender  to  the  touch,  will,  in  months  afterward,  appear 
subnormal  in  size.  Likewise  the  same  lesions  may  be  recognized 
upon  inspection  after  laparotomy,  if  one  has  become  familiar  with 
them  by  previous  study. 

While  hyperplasia  of  the  stroma  is  going  on,  the  follicular  ele- 
ments undergo  certain  changes.  The  contents  of  the  follicles  be- 
come cloudy  from  degeneration  of  the  epithelial  elements.  The 
gross  appearance  of  the  ovary  at  this  time  would  lead  one  to  sup- 
pose that  there  were  a  number  of  vesicles  approaching  maturity, 
but  the  uncommon  number  of  these  is  evidence  that  they  are  ab- 
normal. 

The  full  value  of  a  knowledge  of  the  gross  pathology  of  ovaritis 
can  be  fully  estimated  by  those  who  have  mistaken  the  normal  for  a 
pathological  degeneration  of  the  ovaries,  and  have  removed  them,  to 
learn  subsequently,  through  the  microscopist,  that  they  were  not 
diseased.  The  morbid  appearances  which  aid  the  surgeon  in  decid- 
ing when  to  remove  an  ovary  and  when  not  to  remove  it  are  as  fol- 
lows :  The  presence  of  follicles  which,  from  their  size,  number,  and 
dark  color,  are  evidently  diseased  :  enlargement,  congestion,  and 
softening  from  oedema,  and  patches  of  induration,  with  irregular 
distention  of  the  vessels  and  the  evidence  of  small  blood-clots,  as 
described  above.  Cirrhosis,  indicated  by  subnormal  size,  indura- 
tion, and  irregular  surface,  when  found  in  a  young  subject,  can 
be  easily  passed  upon.  But  in  a  subject  near  or  after  meno]>ause 
this  appearance  of  the  ovary  does  not  enable  the  surgeon  to  decide 
with  certainty  whether  there  is  cirrhosis  or  simply  senile  atrophic 
degeneration. 

Symptoinatology. — The  history  of  chronic  ovaritis  includes  both 
local  and  constitutional  symjitoms.  The  constitutional  derange- 
ments are  not  acute,  but  are  usually  marked  by  depression  of  the 
nutritive  and  nervous  systems.  The  reflex  derangement  of  the 
digestive  organs  is  manifested  by  capricious  appetite,  nausea,  and 
sometimes  gastralgia.  The  bowels  are  usually  consti^^ated  and 
tympanitic.  There  is  often  nervous  del)ility  attended  with  great 
emotional  disturbance.  I  believe  that  I  have  seen  more  marked  de- 
rangement of  the  brain  and  nervous  system  caused  by  chronic  ova- 
ritis than  by  the  reflex  influence  of  any  other  affection  of  the  sexual 
organs.    These  constitutional  symptoms  are  progressive,  the  patient's 


DISEASES   OF   THE   OVARIES.  495 

general  health  becoming  more  impaired  montli  after  month  as  the 
disease  advances.  The  local  manifestations  are  pain  and  derange- 
ment of  menstruation.  There  is  often  menorrhagia  ;  in  fact,  that  is 
the  rule,  but  in  cases  of  long  standing  I  have  seen  amenorrhoea.  The 
ovarian  pain  is  usually  increased  for  several  days  before  menstrua- 
tion, and  is  relieved  to  some  extent  when  the  flow  has  lasted  a  day 
or  two.  The  menstrual  pain  is  much  more  severe  and  persistent  if 
there  be  a  uterine  disease  accompanying  that  of  the  ovaries.  The 
ovarian  pain  varies  according  to  the  ovarian  tissue  affected.  When 
the  stroma  alone  is  the  site  of  the  disease  the  pain  is  less  severe. 
Much  more  suffering  is  experienced  when  there  is  circumscribed 
peritonitis  or  salpingitis. 

All  these  symptoms  are  aggravated  by  standing,  walking,  riding, 
or  sitting  in  a  stooping  position  for  any  great  length  of  time.  Most 
comfort  is  obtained  by  the  recumbent  position.  Sexual  excitation 
and  coitus  cause  so  much  suffering  that  the  patient  shrinks  from 
both.     There  are  exceptions  to  this  rule,  but  not  many„ 

Physical  Signs. — The  ovaries  are  tender  to  the  touch,  and  the 
pain  excited  by  pressure  lasts  for  a  long  time  as  a  rule.  The  char- 
acter of  the  pain  excited  by  the  touch  is  described  as  ovarian. 
When  the  ovary  is  enlarged  or  changed  in  form  it  can  sometimes  be 
made  out  by  the  bimanual  touch.  The  ovary  is  usually  movable, 
and  its  separation  from  the  uterus  can  be  distinguished.  It  will  be 
observed  that  the  symptoms  and  physical  signs  of  chronic  ovaritis 
closely  resemble  those  mentioned  as  occurring  in  ovarian  hyper- 
semia.  The  fact  is  that  the  two  affections  have  many  features  in 
common,  hypertemia  being  a  part  or  the  initial  stage  of  inflamma- 
tion, the  manifestations  of  the  two  affections  are  similar. 

Between  ovaritis  and  ovarian  neuralgia  there  is  a  close  resem- 
blance, but  the  differences  are  also  equally  marked.  In  neuralgia 
there  is  no  evidence  of  inflammation,  it  is  not  continuous,  and  very 
often  the  ovary  is  not  tender.  The  diagnosis  can  only  be  made  by 
a  due  consideration  of  the  history  as  related  to  the  cause,  duration, 
physical  signs,  symptoms,  and  progress  of  the  affection. 

Prognosis. — If  the  patient  has  the  good  fortune  to  be  placed 
early  under  treatment,  the  chances  of  recovery  are  favorable.  This 
is  still  more  certain  if  only  one  ovary  is  affected.  The  disease  may 
go  on  in  one  ovary  to  complete  destruction  of  the  organ  by  hyper- 
plasia of  its  cellular  tissue  and  atrophy  of  its  glandular  elements, 
and  after  this  premature  atrophy  all  suffering  may  subside  except 
occasional  neuralgic  pain ;  and  the  other  ovary  may  perform  the 
ovarian  function.     In  case  the  disease  is  complicated  with  inflamma- 


496  DISEASES  OF  WOMEN". 

tion  of  the  neighboring  peritonaeum,  and  there  is  marked  destruction 
of  tissue  from  the  inflammation,  relief  can  only  be  given  by  remov- 
ing the  ovaries.  There  is  not  a  great  mortality  from  this  affection. 
I  have  never  seen  a  fatal  case,  but  I  have  seen  several  in  which  life 
was  not  worth  living. 

Causation. — The  causation  of  chronic  ovaritis  demands  a  brief 
notice,  owing  to  its  intimate  relation  to  the  question  of  treatment. 
According  to  my  observations,  the  cause  which  most  frequently  ob- 
tains is  imperfect  menstruation.  When  the  uterus  is  undersized  or 
flexed  forward  or  backward,  and  the  menstrual  flow  is  scanty  and  at- 
tended with  pain,  the  ovaries  are  liable  to  take  on  chronic  inflamma- 
tion. This  is  far  more  liable  to  occur  in  this  class  of  subjects  if  the 
sexual  function  is  perverted.  Specific  causes  such  as  produce  tlie 
eruptive  fevers  are  said  to  affect  the  ovaries,  but  I  believe  that  acute 
ovaritis  is  more  liable  to  occur  under  these  circumstances.  It  is 
probably  true,  also,  that  gonorrhoea  causes  acute  rather  than  chronic 
ovaritis. 

The  strumous  diathesis  (which  I  understand  to  be  that  condition 
of  organization  which  invites  tuberculosis)  predisposes  to  chronic 
ovaritis,  and  inherited  or  acquired  syphilis  does  likewise. 

Much  has  been  written  about  endometritis  as  a  cause  of  ovaritis, 
upon  the  theory  that  the  structure  of  the  endometrium  and  that  of 
the  ovaries  have  a  common  embryonic  genesis,  and  the  fact  that  the 
two  diseases  are  often  found  together,  but  this  is  still  an  open  ques- 
tion. 

Surgical  Treatment. — The  advancement  of  abdominal  and  pel- 
vic surgery  in  recent  times  has  led  to  the  removal  of  the  ovaries 
as  the  most  prompt  and  effectual  treatment  of  chronic  ovaritis. 
There  are  reasons  for  this  upon  theoretical  grounds.  The  ovary  is 
causing  much  suffering ;  there  is  a  likelihood  that  it  will  be  a  long 
and  tedious  trouble ;  especially  is  this  the  case  if  general  treatment 
has  failed ;  the  ovaries  are  not  necessary  to  existence,  and  can  be 
removed  with  safety;  it  is  according  to  the  rules  of  surgery  to 
remove  any  organ,  or  other  portion  of  the  body,  that  one  can  live 
without,  in  case  a  disease  of  the  part  tends  to  take  life  or  cause 
unlimited  suffering  and  invalidism;  hence,  from  this  way  of  look- 
ing at  the  matter,  the  ovaries  should  be  removed. 

Tlie  facts  are  (facts  that  have  been  proved  almost  sufficiently), 
that  chronic  ovaritis  does  not  end  fatally,  and  is  self-limited  though 
often  of  long  duration  ;  the  removal  of  the  ovaries  is  not  free  from 
all  danger,  though  all  cases  properly  operated  upon  have  recovered, 
and  it  does  not  in  all  cases  give  complete  relief.     In  fact,  many  of 


DISEASES  OF  THE   OVARIES.  49Y 

the  cases  are  not  much  improved,  if  at  all ;  even  those  who  are  near- 
ing  the  menopause,  and  who  bear  the  loss  of  the  ovaries  better  than 
younger  subjects,  occasionally  suffer  much  from  those  nervous  dis- 
turbances which  follow  an  abrupt  menopause,  and  have  to  endure 
pelvic  pain  in  the  region  of  the  stumps.  The  clinical  history  of 
cases  in  which  the  ovaries  have  been  removed  does  not,  in  all  cases, 
show  great  advantage  over  those  in  which  the  ovaries  are  left  to 
complete  the  natural  history  of  the  disease. 

Younger  subjects  do  not  bear  the  loss  of  their  ovaries  well. 
Some  become  fat,  indolent,  inefficient,  and  subject  to  headaches; 
others  are  irritable,  dyspeptic,  and  despondent ;  while  but  few  enjoy 
good  general  health  and  mental  vigor. 

This  statement  is  at  variance  with  much  of  the  published  litera- 
ture, but  is  more  in  accordance  with  the  actual  facts.  The  cases 
cured  are  those  operated  on  when  near  the  menopause ;  those  who 
are  improved  are  generally  those  who  suffered  from  complicating 
affections,  such  as  dysmenorrhcea ;  while  the  unimproved  are  the 
younger  subjects  in  whom  the  disease  was  uncomplicated. 

The  objections  to  surgical  treatment  apply  to  the  removal  of 
both  ovaries.  In  cases  in  which  one  ovary  alone  is  affected,  and 
especially  where  there  is  prolapsus  of  the  affected  ovary  and  retro- 
displacement  of  the  uterus,  ovariotomy  is  perfectly  satisfactory. 
The  removal  of  the  diseased  ovary  gives  relief,  and  the  retro-dis- 
placed uterus  can  be  restored,  while  the  remaining  ovary  performs 
its  functions,  and  the  general  health  of  the  patient  is  preserved.  I 
desire  to  be  understood  as  advocating  the  removal  of  the  ovary  only 
when  there  are  structural  changes  from  inflammation  and  prolapsus 
at  the  same  time.  Prolapsus  can  be  relieved  by  fixing  the  ovary  to 
the  upper  border  of  the  broad  ligament,  and  the  welfare  of  the 
patient  can  be  thus  conserved  to  a  higher  degree.  When  advocat- 
ing conservative  measures  in  regard  to  abdominal  and  pelvic  surgery 
it  may  be  inferred  that  I  am  behind  the  age  in  experience,  but  I  have 
had  a  large  field  for  operative  surgery,  and  have  acted  to  the  fullest 
extent  justifiable,  according  to  my  judgment.  In  fact,  I  have  in  the 
past  violated  the  rules  I  now  advocate,  but  I  have  not  been  satisfied 
to  have  my  patients  simply  survive  the  operations.  I  require  that 
they  be  cured,  and  failures  in  this  regard  have  led,  I  trust,  to  a  ra- 
tional conservatism. 

I  have  no  word  of  condemnation  for  those  who  have  removed 

and  are  still  removing  ovaries  for  the  relief  of  chronic  ovaritis. 

Their  work,  while  not  always  beneficial,  has  been  of  vast  interest  to 

science.     Their  doings  help  to  perfect   surgery.     The   rough,  un- 

33 


498  DISEASES   OF  WOMEN. 

sightly  scaffoldings  employed  by  builders  are  temporary  necessities, 
which  are  all  cleared  away  when  the  structure  is  perfected  and 
completed.  In  like  manner  the  heroic,  daring  experiments  of  the 
surgeon  are  valuable  stepping-stones  which  lead  to  mature  science 
and  art. 

General  Treatment. — The  indications  for  general  treatment  are  to 
lessen  the  blood-supply  and  relieve  pain  by  correcting  the  deranged 
innervation.  This  demands  rest  in  the  recumbent  position  in  the 
early  stages.  At  the  same  time  general  exercise  should  be  enjoined, 
either  by  massage  or  gymnastic  exercise  in  the  reclining  position.  I 
specially  desire  to  commend  systematic  calisthenics,  in  the  recumbent 
position,  as  a  most  valuable  aid  in  improving  or  maintaining  the  gen- 
eral healtli  in  many  diseases  of  the  pelvic  organs  which  require  rest 
as  an  important  part  of  the  treatment.  The  condition  of  the  diges- 
tive organs  should  be  carefully  watched.  The  poor  appetite,  coated 
tongue,  and  constipation,  or  the  capricious  appetite,  flatulence,  and 
occasional  diarrhoea,  can  be  relieved  by  a  number  of  small  doses 
of  mercury  and  a  laxative.  The  saline  laxatives  are  the  best  when 
they  act  without  causing  flatulence.  The  use  of  Saratoga  waters 
often  gives  good  results  by  improving  digestion  and  keeping  the 
portal  circulation  active.  By  keeping  up  a  free  elimination  by  the 
bowels  and  kidne}s  much  benefit  is  obtained.  This  applies  in  cases 
that  are  apparently  debilitated.  Many  times  I  have  stopped  the 
use  of  tonics,  stimulants,  and  forced  feeding,  and  given  saline  laxa- 
tives, with  the  effect  of  increasing  the  patients'  strength.  To  re- 
lieve the  pain  and  lessen  the  hyperaemia,  the  bromide  of  sodium  and 
fluid  extract  of  hydrastis  canadensis  are  by  far  the  most  potential 
agents  that  I  have  found  ;  they  are  given  in  combination,  and  in 
doses  sutficient  to  produce  the  desired  effect.  Twenty  to  thirty 
grains  of  the  bromide  and  ten  to  twenty  minims  of  the  hydrastis, 
three  times  a  day,  until  the  physiological  effects  of  the  bromide  are 
noticed  in  a  mild  degree.  If  the  hydrastis  is  given  alone,  in  such 
doses,  it  sometimes  causes  pelvic  pain  of  a  dull  character,  but  when 
combined  with  the  bromide  it  has  no  such  effect.  These  agents  are 
most  efficacious  in  the  beginning  of  the  attack,  and  hence  they  should 
be  discontinued  as  soon  as  the  pain  is  relieved  in  a  marked  degree- 
Should  the  pain  and  tenderness  return  at  the  succeeding  menstrual 
periods,  the  bromide  and  hydrastis  should  be  resumed.  In  some 
cases  much  larger  doses  of  bromide  are  required,  and  in  others  it 
fails  altogether  to  relieve  pain.  Then  it  is  necessary  to  employ 
other  agents,  especially  during  menstruation.  Ten-grain  doses  of 
salicylate  of  soda  and  five  of  anti]iyrin,  given  between  meals  and  ini 


DISEASES  OP  THE   OVARIES.  499 

the  niglit,  when  the  stomach  is  empty,  answer  for  some ;  others, 
more  especially  those  markedly  debilitated,  do  better  on  full  doses  of 
aromatic  spirits  of  ammonia,  camphor,  and  chloric  ether,  with  small 
doses  of  cannabis  Indica  This  combination  is  best  suited  to  those 
who  get  relief  from  gin  or  whisky,  but  it  is  to  be  preferred,  as  al- 
coholic stimulants  ultimately  do  harm,  though  they  may  give  tem- 
porary relief.  Direct  or  local  treatment  should  be  adapted  to  the 
social  state  of  the  patient,  and  the  presence  or  absence  of  complica- 
tions, such  as  endometritis.  In  the  unmarried,  local  treatment  is 
often  injurious.  In  fact,  in  such  cases  it  is  better  to  avoid  any  ex- 
amination of  the  pelvic  organs,  if  the  history  is  sufficiently  clear  to 
enable  one  to  make  a  diagnosis  with  reasonable  certainty.  Hot  sitz- 
baths,  counter-irritation,  and  hot  vaginal  douches,  the  latter  to  be 
employed  by  a  competent  nurse,  comprise  about  all  that  I  employ 
in  the  way  of  direct  treatment  The  vaginal  douche  should  not 
be  continued  unless  it  is  decidedly  sedative  in  its  effects.  Baths 
used  according  to  the  rules  of  modern  hydrotherapy  are  of  great 
service. 

In  weak,  nervous  patients  I  begin  with  the  wet-pack,  used  for 
half  an  hour  at  a  time.  Those  who  require  a  sedative  are  put  into 
water  at  a  temperature  of  95°  F.  for  ten  or  twenty  minutes  and  then 
dried  by  brisk  rubbing.  When  the  sedative  effects  of  the  bath  are 
no  longer  needed,  the  tonic  bath  should  be  used.  This  consists  of 
the  cold  sponge,  shower,  or  plunge  bath.  The  water  should  be  warm 
at  first,  and  gradually  reduced  in  temperature  at  each  bath. 

In  married  women  (and  those  who  are  so  in  all  but  the  name) 
local  treatment  is  more  valuable.  The  treatment  of  any  disease  or 
displacement  of  the  uterus  that  coexists  should  be  managed  in  the 
usual  way,  and  such  local  applications  should  be  used  as  may  aid  in 
relieving  the  tender  and  hypersemic  ovaries.  I  employ  a  small  tam- 
pon or  pledget  of  cotton  or  wool  saturated  with  equal  parts  of  tinct- 
ure of  belladonna  and  glycerin,  applied  behind  the  cervix  uteri  and 
permitted  to  remain  forty-eight  hours,  and  after  its  removal  a  hot 
douche.  These  are  continued  during  the  first  days  of  treatment. 
The  effect  is  to  support  or  steady  the  ovaries,  while  the  sedative  ef- 
fect of  the  belladonna  and  the  depleting  effect  of  the  glycerin  are 
obtained.  This  I  have  followed  with  applications  of  tincture  of 
iodine,  after  the  manner  of  Dr.  Emmet.  Recently  I  have  used,  with 
good  effect,  the  sulphichthyolate  of  ammonium,  five  parts  in  nine- 
ty-five of  glycerin,  applied  in  the  same  way  as  the  belladonna  and 
glycerin. 

The  general  and  local  treatment  thus  briefly  outlined  gives  re- 


500  DISEASES  OP   WOMEN. 

lief  from  the  more  pronounced  symptoms.  The  pain  becomes  less, 
and  the  tenderness  also.  The  general  health  improves,  and  the  pel- 
vic congestion  subsides.  This  is  apparent  in  the  color  of  the  mucous 
membrane,  the  improvement  of  the  menstrual  functions,  and  the 
diminished  leucorrhcea.  Then  the  local  treatment  may  be  employed 
at  longer  inter v^als,  or  suspended  altogether.  The  constitutional 
treatment  should  now  be  modified.  Tonics  and  laxatives  may  still 
be  required,  but  alteratives  are  also  indicated.  Iodine  and  mercury 
are  the  chief  agents.  They  act  upon  the  ovaries,  as  they  do  upon  all 
glandular  organs,  and  modify  or  arrest  the  morbid  histological 
changes  which  take  place  slowly.  Small  doses  of  bichloride  of 
mercury,  with  chloride  of  iron,  when  iron  is  indicated,  followed  by 
syrup  of  the  iodide  of  iron  in  doses  as  large  as  can  be  borne.  These 
can  only  be  used  when  the  bromides  are  relinquished.  When  giv- 
ing these  alteratives  the  patient  often  misses  the  bromides  used  to 
produce  sleep.  Sulphonal  at  such  times  is  of  great  value.  In  fact, 
it  is  the  most  potent  sedative  that  is  at  the  same  time  free  from 
ultimate  or  after  effects  that  are  unfavorable  that  we  have  in  gynae- 
cological practice.  When  a  sedative  is  required  while  iodine  or 
mercury  is  being  used,  I  find  that  ten  grains  of  salicylate  of  sodium 
and  five  grains  of  antipyrin,  three  times  a  day  an  hour  before  meals, 
give  much  relief,  especially  in  those  who  suffer  from  nervous  dys- 
pepsia and  flatulence. 

Important  elements  in  the  treatment  are  patience  and  careful 
watching.  Improvement  comes,  and  the  patient  or  the  physician 
gives  up  treatment,  and  there  is  danger  of  relapse.  The  poor  in 
hospitals  often  suffer  for  M^ant  of  time  for  prolonged  treatment,  and 
this  frequently  tempts  the  surgeon  to  seek  more  prompt  relief  by 
removal  of  the  ovaries.  This  does  not  api)ly  with  the  same  force 
to  those  who  have  time  and  means  to  secure  the  needed  care. 

The  description  of  the  operation  for  the  removal  of  ovaries  de- 
stroyed by  inflammation,  as  well  as  that  for  the  removal  of  diseased 
tubes,  will  ])e  found  at  page  590. 

Displacement  of  the  Ovaries. — The  ovaries  have  been  found  dis- 
located in  a  variety  of  ways.  Cases  are  recorded  in  which  the  ova- 
ries descended  through  tlic  inguinal  canal  after  the  manner  of  the 
testicles.  The  most  interesting  of  these  is  one  reported  by  Percival 
Pott,  who  removed  both  ovaries  that  were  found  in  the  usual  posi- 
tion of  an  inguinal  hernia  ;  and  still  another  is  mentioned  by  Tait,  in 
which  the  ovary  found  its  way  outside  of  the  inguinal  ring  and  there 
developed  a  cystic  tumor,  which  was  removed  by  a  Spanish  surgeon. 
The  ovaries  have  been  found  dislocated  laterally  and  high  up  in  the 


DISEASES  OP  THE  OVARIES.  501 

pelvis.  Thej  are,  in  sucli  cases,  usually  fixed  in  tlie  malposition  by- 
adhesions. 

Prolapsus  of  the  Ovaries. — Downward  dislocation  of  the  ovaries 
is  quite  a  common  att'ection  compared  with  all  the  other  displace- 
ments. It  is  tlie  only  affection  of  this  class  which  has  an  interest 
to  the  gynecologist  derived  from  the  frequency  of  its  occurrence  and 
the  great  suffering  to  which  it  gives  rise.  On  that  account  it  de- 
serves more  than  a  passing  notice,  such  as  I  have  given  to  the  other 
forms  of  displacement  of  the  ovaries. 

Prolapsus  of  the  ovaries  I  have  described  as  occurring  in  two 
degrees — complete  and  incomplete.  This  classification  is  based  upon 
the  fact  that  displacements  of  the  ovaries  must  in  practice  have  the 
natural  division.  In  the  incomplete  form  the  ovary  has  simply  de- 
scended from  its  normal  position  until  it  has  reached  the  side  of  the 
sac  of  Douglas  or  the  utero-sacral  ligament,  where  it  lodges.  In  the 
complete  form  the  ovary  rests  in  the  most  dependent  portion  of  the 
sac  of  Douglas.     Fig.  213  shows  the  position  of  the  ovary  in  com- 


FiG.  213. — Ovary  displaced  and  bound  down  in  the  cul  de  sac  by  adhesions,     ro,  right 

ovary ;  lo,  left  ovary. 

plete  and  incomplete  prolapsus,  and  the  relation  of  the  prolapsed 
organ  in  relation  to  the  uterus  and  sac  of  Douglas.  The  figure 
also  shows  what  is  sometimes  found  in  practice — namely,  complete 
prolapsus  of  one  ovary  and  incomplete  prolapsus  of  the  other  occur- 
ring in  the  same  subject.  "While  prolapsus  of  both  ovaries  in  dif- 
fering degrees,  or  both  in  the  same  degree,  may  occur,  I  more  fre- 
quently find  one  displaced,  while  the  other  is  in  its  normal  position. 


502  DISEASES  OF  WOMEN. 

The  left  is  the  one  most  frequently  displaced,  or  else  it  causes  the 
most  suffering,  and  on  that  account  attracts  more  attention  than  the 
right,  and  is  oftener  discovered. 

Prolapsus  necessitates  a  stretching  of  the  supports  of  the  ovary, 
or  it  may  be  an  elongation  from  an  increase  of  tissue,  the  result  of 
hyperplasia  or  new  development.  Prolapsus  does  occur  without 
complications  or  coexisting  affections,  which  cause  the  displacement. 
Such  cases  are  not  very  common,  and  they  are  probably  the  result 
of  arrest  of  development.  In  many  cases,  perhaps  the  majority, 
there  is  some  accompanying  affection  which  has  some  part  in  the 
causation  of  the  prolapsus.  The  ovary  itself  is  often  enlarged  from 
inflammation  or  some  degenerative  changes.  In  other  cases  the  sup- 
ports of  the  ovary  are  elongated  from  imperfect  involution  after  con- 
finement. Retroversion  of  the  uterus  is  also  frequently  associated 
with  prolapsus  of  the  ovary.  A  not  uncommon  and  a  very  unfor- 
tunate complication  is  the  formation  of  adhesions  from  peritoneal 
inflammation. 

Symptomatology. — The  degree  of  suffering  arising  from  disloca- 
tion of  the  ovaries  is  extremely  varying  in  different  cases.  This  is 
due  largely  to  the  fact  that,  if  the  ovaries  are  quite  normal  and  sim- 
ply displaced,  but  little  Inconvenience  is  experienced  by  the  patient. 
It  is  rare  to  find  this  state  of  things,  because  the  ovaries  are  often 
diseased,  or  else  displacement  soon  leads  to  congestion,  tenderness, 
and  pain.  As  a  rule,  then,  in  displacement  of  the  ovaries  there  is 
pelvic  tenesmus  and  pain  on  walking  or  standing,  relief  from  which 
is  obtained  by  the  recumbent  position.  In  this  the  history  differs 
from  inflammation  of  the  ovaries.  There  is  usually  backache  and  pain 
along  the  thighs,  and  pain  and  tenderness  during  and  after  sexual 
intercourse.  There  is  pain  after  defecation,  especially  when  the  left 
ovary  is  displaced,  which  is  most  frequently  the  case.  This  pain  is 
peculiar  and,  I  believe,  diagnostic.  It  conies  on  during  or  imme- 
diately after  the  action  of  the  bowels,  and  continues  for  an  hour  or 
two.  It  is  a  dull,  aching  pain  located  in  the  region  of  the  ovary, 
and  radiates  to  the  abdomen.  It  produces  in  many  cases  faintnesa 
and  nausea,  compelling  the  patient  to  lie  down  until  it  subsides.  It 
is  easily  distinguished  from  the  acute,  smarting  pain  due  to  hfemor^ 
rhoids  or  fissure  of  the  anus,  on  account  of  its  location  and  character. 
There  is  in  some  cases  derangement  of  menstruation,  usually  menor- 
rhagia.  The  pain  in  the  ovary  is  generally  aggravated  at  the  men- 
strual period.  The  constitutional  symptoms  are  generally  produced 
from  the  confinement  of  the  patient,  made  necessary  by  the  suffer- 
ing caused  by  taking  active  exercise.     There  is  often  headache 


DISEASES   OF   THE  OVARIES.  503 

mental  depression,  indigestion,  and  ana3tnia,  ending  in  general  de- 
bility. It  should  be  understood  that  the  symptoms  alone  will  not 
suflSce  to  make  a  diagnosis,  because  in  many  cases  they  arise  more 
directly  from  the  condition  of  the  ovary  rather  than  from  its  mal- 
position. 

Physical  Signs. — The  method  of  making  a  vaginal  examination 
by  the  touch,  to  detect  a  prolapsus  of  the  ovaries  is  as  follows :  The 
finger  should  be  carried  as  far  upward  on  either  side  of  the  cervix 
uteri  as  the  vaginal  wall  will  permit,  and  then  brought  downward 
toward  the  sacrum,  so  that  if  the  ovary  is  displaced  it  will  be  caught 
between  the  examining  finger  and  the  sacrum.  In  that  way  it  can 
be  outlined  by  palpation,  and  its  sensitiveness  determined.  Its 
mobility  or  fixation  can  also  be  determined  in  this  way.  I  have 
frequently  found  while  teaching  my  class  of  post-graduates  that 
these  few  hints  would  enable  them  to  find  the  displaced  ovaries 
when  they  had  tried  in  vain  to  make  out  their  location.  When  an 
ovary  is  completely  prolapsed,  it  is  found  directly  behind  the  cervix 
uteri  in  the  most  dependent  portion  of  the  sac  of  Douglas.  So  ex- 
actly central  is  the  position  of  the  ovary  that  in  most  of  my  cases  I 
could  not  tell  whether  it  was  the  right  or  left  ovary,  and  could  only 
settle  that  question  by  finding  the  other  one  in  its  normal  position. 
If  the  prolapsus  is  incomplete  the  ovary  is  found  on  one  side  of 
the  cervix  uteri,  usually  at  a  point  a  little  above  the  junction  of  the 
body  and  cervix.  In  complete  prolapsus  the  ovary  feels  not  unlike 
the  fundus  uteri,  and  gives  the  impression  of  retroflexion  of  the 
uterus.  The  distinction  can  be  made  by  the  peculiar  sensitiveness 
of  the  ovary  to  pressure,  and  by  the  fact  that  the  finger  can  usually 
be  insinuated  between  the  uterus  and  the  ovary.  Should  there  still 
be  a  doubt,  the  question  can  be  solved  by  passing  the  sound  which 
will  exclude  flexion  of  the  uterus. 

There  is  another  condition  which  proves  to  be  somewhat  puz- 
zling, that  is  complete  prolapsus  of  the  ovary  with  the  retro  verted 
uterus  lying  directly  upon  and  above  it.  In  one  such  case  which 
came  under  my  care,  I  was  able  to  make  out  the  true  state  of  affairs 
by  passing  the  sound,  and  while  it  was  in  place  raising  the  uterus 
far  enough  to  lift  it  off  the  ovary,  so  that  by  the  touch  I  could  dis- 
tinguish the  one  from  the  other. 

Prognosis. — The  prospect  of  permanently  overcoming  the  dis- 
placement depends  upon  the  length  of  time  that  the  malposition  has 
existed;  upon  the  condition  of  the  ovarj',  whether  nonnal  or  diseased, 
and  whether  there  are  other  complications,  such  as  adhesions,  retro- 
version, or  retroflexion  of  the  uterus.    In  recent  uncomplicated  cases 


504  DISEASES  OF  WOMEN. 

a  permanent  restoration  may  be  effected  if  the  patient  Can  be  kept 
under  treatment  for  a  sufficient  length  of  time.  In  complicated 
cases  all  ordinary  local  treatment  fails.  It  is  then  that  the  question 
of  advisability  of  removing  the  ovaries  comes  up  for  consideration. 
Should  the  patient  be  near  the  menopause,  she  may  be  carried  along 
past  that  change,  and  the  recovery  may  come.  In  younger  subjects 
the  ovaries  should  be  removed  if  all  else  fails  to  give  relief. 

Causation. — The  following  are  the  causes  of  displacement  of  the 
ovaries,  named,  as  far  as  my  knowledge  guides  me,  in  the  order  of 
their  frequency. 

Subinvolution ;  enlargement  of  the  ovaries  from  hypertemia, 
ovaritis,  or  other  affections ;  displacements  of  the  uterus ;  congenital 
malposition  from  derangements  of  development  and  growth.  In 
regard  to  subinvolution,  it  may  be  well  to  call  to  mind  the  fact  that 
in  the  puerperal  state,  the  ovaries — especially  the  left  one — are  very 
large,  nearly  twice  as  large  as  at  other  times,  and  if  care  is  not  taken 
to  secure  complete  involution  after  confinement  the  heavy  ovaries 
will  naturally  descend,  and  by  making  traction  upon  the  peritonaeum 
and  ligaments  will  overstretch  them.  I  believe  also  that  subinvolu- 
tion of  the  broad  ligaments  will  permit  the  ovaries  to  descend  into 
the  pelvis  when  they  are  not  much  enlarged.  At  any  rate,  I  have 
found  the  ovaries  prolapsed  when  they  were  not  large,  but  wlien  the 
broad  ligaments  were  long  and  relaxed,  a  condition  which  followed 
confinement.  In  regard  to  the  other  causes  of  prolapsus  of  the  ova- 
ries they  are  sufficiently  clear  to  warrant  my  saying  nothing  more 
about  them. 

Ti'satmiient. — The  first  thing  to  do  is  to  ascertain  if  the  displaced 
ovary  is  movable  and  can  be  raised  uj)  to  its  normal  position.  If 
that  can  not  be  accomplished,  owing  to  adhesions,  then  there  is  little 
to  be  hoped  for  from  treatment.  When  the  ovary  is  movable  it  can 
be  placed  in  position  by  putting  the  patient  in  the  knee-chest  posi- 
tion, using  a  Sims's  speculum,  and  then  making  upward  pressure 
through  the  vaginal  wall  with  a  sponge  held  in  a  sponge-holder.  In 
short,  the  same  method  is  employed  as  in  restoring  a  retro  verted 
uterus.  To  keep  the  ovary  in  place  the  cotton  tampon  is  the  best. 
It  should  be  removed  every  forty-eight  hours,  and  two  or  three  times 
daily  the  patient  should  take  the  knee-chest  position  if  she  is  able  to 
be  up  from  bed  during  the  day.  The  use  of  the  tampon  in  this  way 
takes  much  time,  and  I  have  taught  several  of  my  nurses  to  use  it 
with  very  satisfactory  results. 

Prof.  Goodell  recommended  that  the  patient  should  separate  the 
labia  while  in  the  knee-chest  position,  in  order  to  distend  the  vagina 


DISEASES  OF  THE   OVARIES  505 

with  air,  and  Dr.  C.  F.  Campbell  uses  for  the  same  purpose  a  glass 
tube  open  at  both  ends,  which  is  introduced  into  the  vagina  before 
the  patient  takes  the  knee-chest  position.  I  have  tried  both  of  these 
methods,  but  have  given  them  up  for  two  reasons :  In  the  first 
place,  because  distention  of  the  vagina  is  unnecessary.  In  the  knee- 
chest  position  the  pelvic  organs  will  rise  high  enough  and  assume 
their  normal  position  as  well  with  the  vagina  closed  as  open  ;  of 
this,  any  one  can  satisfy  one's  self  by  making  an  examination  before 
and  after  this  position  has  been  assumed.  In  the  second  place,  I 
find  that  the  less  local  treatment  patients  give  themselves  the  better 
it  is  for  them.  The  first  medical  book  of  any  kind  that  I  ever  read 
was  entitled  "  Every  Man  his  own  Physician,"  by  one  Dr.  Buchan. 
It  was  a  very  useless  production,  but  had  the  good  effect  of  preju- 
dicing me  against  making  every  woman  her  own  gynecologist.  I 
much  prefer  the  tampon  and  the  knee-chest  position.  If  there  is 
retroversion  or  flexion  of  the  uterus  present  at  the  same  time,  that 
organ  should  be  replaced  each  time  that  the  tampon  is  changed. 
When  considerable  has  been  gained  by  the  above  treatment,  and  the 
ovaries  and  uterus  are  replaced  sufliciently  to  get  a  pessary  under 
them,  one  should  be  introduced.  The  form  of  instrument  and  the 
method  of  using  it  are  the  same  as  in  retroversion  of  the  uterus  and 
need  not  be  detailed  here.  I  have  tried  the  special  forms  of  pessa- 
ries recommended  by  Tait,  Munde,  and  others,  but  have  not  been 
able  to  do  as  well  with  them  as  with  the  instrument  which  I  employ 
in  retroversion  of  the  uterus.  In  a  few  cases  I  have  succeeded  in  forc- 
ing the  uterus,  ovaries,  and  vaginal  wall  upward  and  backward,  thus 
giving  some  relief  for  a  time,  but  the  traction  upon  the  vaginal  wall 
causes  stretching,  and  when  the  pessary  is  removed  the  dis23lacement 
returns  to  a  degree  as  great  if  not  greater  than  before. 

AVhile  this  local  treatment  is  employed  every  effort  should  be 
made  to  improve  the  patient's  general  health.  Rest  should  be  in- 
sisted upon,  in  the  recumbent  position  at  first,  and  as  the  case 
progresses  favorably,  short  stages  of  exercise  may  be  permitted. 
Throughout  the  whole  treatment  all  sexual  relations  should  be  pro- 
scribed. 

When  all  other  treatment  fails,  and  the  patient  still  remains  a  use- 
less invalid,  the  ovaries  should  be  removed,  or  attached  to  the  upper 
margin  of  the  broad  ligament  or  abdominal  wall. 


CHAPTER  XXYIL 

NEOPLASMS  OF  THE  OVARIES. 

I  HAVE  made  a  classification  of  the  morbid  growths  of  the  ova- 
ries whicli  I  believe  will  best  serve  the  practical  requirements  of 
the  gynecologist,  although  it  may  not  be  quite  in  keeping  with  the 
arrangement  of  the  subject  usually  found  in  the  text-books.  In  fact, 
it  would  be  hardly  possible  to  make  any  classification  which  would 
agree  with  all  of  the  many  authorities  on  the  subject.  Nor  would  it 
be  possible  to  present  an  argument  in  favor  of  the  classification  which 
I  have  adopted  without  either  taking  more  time  and  space  than  I 
can  afford,  or  else  omitting  to  mention  the  statements  of  many 
whose  views  are  well  worthy  of  consideration.  I  am  obliged  to  sim- 
ply state  in  brief  that  which  to  my  mind  appears  necessary  to  the 
student  and  practitioner. 

The  first  class  is  made  up  wholly  of  cystic  tumors,  with  a  single 
exception,  to  which  I  shall  refer  later,  and  of  these  there  are  two 
varieties — follicular  cysts  and  adenoid  cystomata.  Both  of  these  va- 
rieties occur  in  a  simple  and  in  a  compound  form.  Thus  we  may 
have  {a)  simple  unilocular  cystoma,  and  (b)  simple  follicular  cysts,  or 
of  the  compound  form  we  may  have  (c),  multiple  follicular  cysts, 
{d)  multiple  cystoma,  (."')  multilocular  cystoma,  {/)  papillary  cys- 
toma, and  {(j)  dermoid  cystoma  ;  and  also  {h)  fibrous,  and  {i)  cysto- 
fibroma. 

The  second  class,  which  many  speak  of  as  malignant  growths, 
contains  four  varieties :  {a)  carcinoma,  {1>)  cysto-carcinoma,  (e)  sar- 
coma, and  {(l)  cysto-sarcoma. 

Classification. — Tliese  morbid  growths  I  have  arranged  in  two 
classes : 

1.  Those  that  arc  most  frequently  seen  in  practice,  and  that  are 
to  some  extent  amenable  to  surgical  treatment. 

2.  Those  that  are  rarely  met  with,  and  that  resist  all  kinds  of  sur- 
gical treatment,  and  tend  by  their  very  nature  to  a  fatal  termination. 

506 


NEOPLASMS  OF  THE   OVARIES.  507 

Tumors  of  the  first  class  are  spoken  of  by  some  authorities  as 
benign,  while  the  term  malignant  is  applied  to  those  which  I  have 
placed  in  my  second  class, 

OVARIAN   CYSTS. 

Pathology. — The  kind  of  ovarian  neoplasm  most  frequently  seen 
is  the  cystic  tumor,  or  ovarian  cyst,  as  it  is  generally  called. 

The  development  and  growth  of  ovarian  cysts  and  cystomata 
vary  in  different  cases  in  many  respects,  and  still  there  is  a  certain 
sameness  in  the  majority.  The  growth  of  these  has  been  divided 
into  three  stages,  the  division  being  based  upon  certain  features  of  the 
natural  history  of  these  neoplasms  rather  than  upon  any  changes  in 
their  pathology.  In  the  first  stage  the  tumor  is  small,  and  confined 
to  the  pelvic  cavity.  This  stage  begins  with  the  formation  of  the 
morbid  growth  and  ends  when  it  is  large  enough  to  rise  out  of  the 
pelvis  into  the  abdominal  cavity.  The  duration  of  this  stage  can  not 
be  estimated,  because  there  is  no  way  by  which  the  morbid  growth 
can  be  detected  until  it  has  attained  considerable  size.  In  many 
cases  an  ovarian  tumor  gives  rise  to  no  marked  disturbance,  and 
therefore  remains  unnoticed  until  it  has  reached  the  second  stage. 
This  stage  begins  when  the  tumor  rises  up  into  the  abdomen, 
and  ends  when  the  patient's  general  health  begins  to  deteriorate. 
These  constitutional  effects  of  the  morbid  growth  mark  the  begin- 
ning of  the  third  stage.  The  first  stage  often  passes  by  without  the 
presence  of  any  abnormality  being  suspected.  It  is  only  when  press- 
ure upon  the  pelvic  organs  or  when  some  inflammatory  action  in 
the  ovary  or  pelvic  peritonaeum  occurs,  that  there  is  any  likelihood 
of  the  affection  being  discovered.  There  is  reason  to  believe,  from 
the  cases  which  have  been  M-atched,  that  the  growth  is  steadily  pro- 
gressive as  it  is  in  other  neoplasms.  The  natural  history  of  non- 
malignant  tumors  is  that  they  go  on  gradually  increasing  until  they 
attain  a  size  sufficient  to  destroy  life.  This  requires  from  two  to 
three  years  on  the  average,  but  there  is  a  great  variation  in  time 
in  different  cases.  There  are  periods  of  cessation  of  growth  followed 
by  rapid  increase  in  size.  These  alternations  of  increase  and  pas- 
siveness  may  occur  repeatedly,  or  the  progress  may  be  continuous. 

In  the  third  stage  the  general  health  of  the  patient  begins  to 
suffer.  ■  There  is  usually  loss  of  flesh,  and  the  face  shows  evidence 
of  ill-health.  A  certain  facial  expression  has  been  described  as  the 
facies  ovarii,  but  this  is  difficult  to  describe  or  recognize.  It  may 
be  said  to  be  an  emaciated,  careworn  appearance,  without  the  bronze 
hue  of  the  cachectic  state.     This  malnutrition  is  due  at  first  to  ex- 


508 


DISEASES  OF  WOMEN. 


haustion  from  the  growth  of  the  tumor,  and  finally  to  pressure 
upon  the  neighboring  organs.  The  functions  of  the  abdominal  and 
thoracic  organs  become  deranged  from  pressure,  and  cause  exhaus- 
tion and  death  by  slow  degrees. 

Death  sometimes  comes  suddenly  from  asphyxia  due  to  pressure 
upon  the  thoracic  organs.  Sometimes  peritonitis  is  the  immediate 
cause  of  death.  In  the  majority  of  cases  that  are  permitted  to  run 
their  course,  the  patient  is  slowly  crowded  out  of  existence  by  the 
enormous  size  of  the  tumor.  Fortunately,  there  are  few  cases  in 
this  age  that  are  permitted  to  be  lost  in  this  way. 

Toward  the  end  of  the  third  stage  oedema  of  the  limbs  generally 
appears.  This  is  more  likely  to  occur  if  the  patient  is  unable  to  lie 
down  in  bed. 

The  simple  cyst  is  the  most  easily  comprehended,  and  will  there- 
fore be  first  described.  It  is  composed  of  the  cyst  proper  and 
the  pedicle.  The  cyst  is  made  up  of  the  cyst-wall  and  the  contained 
fluid. 

The  pedicle  is  usually  composed  of  the  ovarian  ligament. 
Fallopian  tube,  and  part  of  the  broad  ligament.  The  cyst  and 
the  pedicle  have  one  covering  in  common — namely,  the  perito- 
naeum. 

Simple  Cysts. — The  simple  cyst  is  usually  globular  in  form,  and 
its  walls  are  generally  of  uniform  thickness.     The  size  varies  in  dif- 


Fio.  214. — Left  ovary  distended  into  one  large  cyst,  into  the  interior  of  which 
smaller  cysts  project  (Farre). 


ferent  cases  from  a  microscopic  object  to  one  weighing  one  hundred 
pounds  or  more,  according  to  the  age  of  the  growth.     By  the  term 


NEOPLASMS  OF  THE   OVARIES. 


509 


simple  or  unilocular  cyst  it  is  not  intended  to  imply  that  the  tumor 
is  absolutely  composed  of  a  single  cyst,  since  it  is  believed  by  the 
best  authorities  that  ovarian  cysts  are  always  multiple,  but  the  term 
is  applied  to  that  variety  of  cyst  v^^]lich  in  its  gross  anatomy  appears 
to  be  single,  and  which  can  be  managed  by  the  surgeon  as  a  single 
cyst.  The  one  sac  or  cyst  is  large  and  appears  to  be  single,  but 
on  close  inspection  minute  cysts  are  generally  found  in  varying 
numbers  in  the  major  cyst,  or  in  that  portion  of  it  which  joins  the 
pedicle. 

Compound  Cysts. — These  are  distinguished  from  the  simple  vari- 
ety by  being  multiple — that  is,  the  whole  tumor  or  mass  is  formed 
by  the  aggregation  of  several  simple  cysts,  each  being  large  enough 
to  be  easily  recognized.  The  usual  form  of  this  multiple  variety  of 
cyst  is  that  in  which  one  of 
the  divisions  or  cysts  is  much 
larger  than  all  the  others  taken 
together.  The  greater  con- 
tains the  lesser  ones,  which  are 
usually  formed  in  a  cluster 
attached  to  one  side  of  the 
major  C3^st,  near  the  pedicle. 

It  will  be  observed  that  the 
difference  between  the  single 
and  multiple  cyst  is,  that  in 
the  latter  there  are  a  number 
of  well-defined  cysts,  one  large 
one  and  a  number  of  others 
varying  in  size  from  that  of  a 
man's  head  to  a  small  hazel- 
nut, while  the  former  is  com- 
posed of  one  cyst  with  a  few 
almost  imperceptible  cysts. 

Multilocular  Cysts.  —  These 
are  so  called  because  the  sacs  or 
cysts,  which  in  the  aggregate 
make  up  the  w^hole  tumor,  are 
larger  in  size  and  more  nearly 

equal.  The  general  appearance  of  the  mass  is  of  one  large  cyst- 
wall  containing  a  number  of  cysts  which  vary  in  size.  Sometimes 
one  or  more  of  the  cysts  is  much  larger  than  the  others.  In  other 
cases  there  are  several  cysts  varying  in  size  from  that  of  a  human 
head  to  that  of  an  orange,  with  a  large  number  of  smaller  cysts. 


Fig.  215. — Compound  and  proliferating  cjst 
(Farre). 


510 


DISEASES  OF  WOMEN. 


From  tlie  general  appearance  and  arrangement  it  would  seem 
that  the  cysts  included  within  the  major  cyst-wall  had  been  de- 
veloped from  the  inner  cyst-wall,  and  others  still  had  been  de- 
veloped from  the  second  crop  by  a  process  of  endogenous  pro- 
liferation.     This    may   or   may   not   be   the   fact,  but  it  is  more 


Fig.  216. — Multilocular  cyst  (Hooper). 


likely  that  the  ovary  from  which  the  morbid  growth  is  developed 
contains  a  number  of  germs  included  in  the  structure  of  tlie 
ovary  which  forms  the  cyst-wall,  and  that  they  all  grew  from 
similar  germs  and  are  aggregations  rather  than  proliferations. 
The  gross  appearance  of  such  tumors  is  the  chief  point  of 
interest  to  the  surgeon,  viz.,  that  one  cyst-wall  contains  within  it 
a  number  of  cysts ;  usually,  there  are  one  or  two  large  cysts, 
a  larger  number  of  medium  size,  and  a  very  great  number  of 
small  ones  varying  in  size  and  united  to  each  other.  The  cavi- 
ties of  these  cysts  rarely  communicate  with  each  other.  Occa- 
sionally a  cyst  is  found  the  cavity  of  which  is  divided  by  septa, 
but  associated  with  such  there  is  always  a  number  of  independ- 
ent cysts. 

I  have,  on  one  occasion,  seen  two  cystomata  growing  from  an 
ovary,  one  on  each  side,  the  whole  resembling  somewhat  a  dumb- 
bell in  shape. 

Complex  Cystoma. — These  tumors  are  called  complex  or  mixed 
because  they  differ  from  those  already  described  by  the  addition  to 
the  cyst  structures  of  other  pathological  elements,  or  else  there  is  a 
marked  development  of  some  special  portion  of  the  cyst  elements — 
the  cyst-wall,  for  example. 

These  peculiar  portions  of  the  growth  may  consist  of  a  hyper- 


NEOPLASMS  OF  THE  OVARIES.  511 

trophic  increase  in  the  tissues  of  an  ovarian  folhcle,  or  of  hyper- 
trophy of  the  stroma  of  the  ovary,  infiltrated  with  serum  or  other 
morbid  fluids.  Proliferation  of  the  fibrous  tissue  may  give  rise  to 
one  or  more  fibrous  masses  connected  with  the  cyst.  The  cyst-wall 
may  be  greatly  thickened  generall}'-,  or  in  certain  portions,  from 
hypertrophy  of  either  its  inner  or  middle  layer.  The  inner  surface 
or  hning  membrane  of  a  cyst  may  develop  new  structures  or  pro- 
liferations. Again,  the  contents  of  a  cyst  may  be  of  a  character  en- 
tirely different  from  the  ordinary  fluid  found  in  simple  or  com- 
pound cystic  tumors.  In  this  way  the  following  complex  tumors 
are  formed  : 

Papillary  Cysts. — In  this  form  of  cyst  the  connective  tissue  of 
the  cyst-wall  undergoes  hyperplasia  in  certain  places,  and  the  growth 
of  the  tissue  pushes  the  lining  membrane  of  the  cyst  before  it,  and 
in  that  way  a  great  number  of  papillae  are  found  projecting  into  the 
major  cyst  and  covering,  it  may  be,  the  whole  internal  surface  of 
the  sac.  The  papillae  are  sometimes  very  vascular,  and  are  covered 
with  columnar  epithelium. 

Paroophoritic  Cysts. — These  cysts,  which,  as  their  name  implies, 
are  developed  in  the  paroophoron,  present,  according  to  Bland  Sut- 
ton, the  following  differences  from  oophoritic  cysts  (the  ordinary 


Fig.  217. — Papillary  cystoma  of  ovary  showing  proliferation  (Winckel). 

ovarian  cysts) :  They  are,  as  a  rule,  unilocular ;  do  not  affect  the 
shape  of  the  ovary  until  they  have  attained  an  important  size  ;  always 
burrow  between  the  layers  of  the  mesosalpinx ;  when  large,  make 
their  way  between  the  layers  of  the  broad  ligament  by  the  side  of  the 
uterus,  and  their  interior  is  beset  with  warts,  which  are  very  vascu- 
lar, bleed  freely,  and  are  frequently  calcified.     It  is  to  be  borne  in 


512 


DISEASES  OF  WOMEN. 


mind,  however,  that  although  these  paroophoritic  cysts  contain  warts 
or  papilloinata,  still  other  cysts  may  also  be  papillomatous. 

Dermoid  Cysts. — Ovarian  dermoids  occur  much  more  frequently 
than  is  generally  thought.  According  to  Olshausen,  they  form  four 
per  cent  of  all  ovarian  tumors.  In  them  have  been  found  hair, 
sebaceous  glands,  sweat  glands,  teeth,  mammse,  horn,  nails,  bone, 
nnstriped  muscle,  a  well-formed  heart,  a  tongue,  a  trachea,  an  eye, 
and  what  has  been  regarded  as  brain  tissue.  They  occur  at  almost 
every  period  of  life.  It  is  said  that  they  have  been  found  at  birth, 
but  Bland  Sutton,  who  has  studied  the  subject  of  dermoids  most 
thoroughly,  is  unable  to  find  the  evidence  of  so  early  a  case.     He 


Fi3.  218. — Dermoid  cyst  of  ovary,  filled  with  hair  and  tallow-like  masses 

(Winckel). 


refers  to  an  authenticated  one  in  a  child  of  one  year  and  eight 
months.  They  have  also  been  found  in  patients  above  eighty  years 
of  age. 

Various  theories  have  been  advanced  to  explain  their  formation. 
The  one  which  seems  to  me  the  most  plausible  is  that  of  A.  W. 
Johnstone,  ]\I.  D.,  of  Cincinnati.  He  regards  the  process  as  a  true 
parthenogenesis,  in  which  the  ovum  itself  is  at  fault.  For  some 
unexplained  and  probably  inexplicable  reason  it  retains  one  of  its 
polar  cells  and  goes  on,  under  the  stimulus  of  this  male  element,  to 
form  a  human  body  in  a  weak  and  very  incomplete  way,  giving  us 
the  great  variety  of  tissues  already  mentioned  as  having  been  found 
as  constituents  of  dermoids.  As  a  consequence,  while  the  hypertro- 
phic change  which  takes  place  in  other  ovarian  follicles  produces 
ordinary  cystomata,  that  which  occurs  in  a  follicle  in  which  exists 
an  ovum  that  still  retains  a  polar  cell  will  result  in  the  formation  of 
a  dermoid. 


NEOPLASMS   OF   THE   OVARIES. 


513 


Cysto-Fibroma.  —  In  tlils  form  of  tumor  tlie  fibrous  portions 
closely  resem1)le,  in  structure,  fibrous  tumors  of  the  uterus.  They 
do  not  diflier  in  their  outward  appearance  from  the  ordinary  simple 
cyst,  but  the  touch  shows  one  part  of  the  mass  to  be  solid  and  the 
other  fluid.  These  morbid  growths  are  quite  rare.  I  have  met  with 
but  two  in  my  own  practice. 


FIBROMA    OF    THE    OVARIES. 


This  rare  form  of  ovarian  tumor  I  have  classed  with  the  cys- 
tomata,  not  because  it  presents  any  features  in  common  with  the 
class,  but  because  it  calls  for  surgical  interference  and  does  not  in 
any  way  belong  to  the  second  class,  having  no  inherent  tendency  to 


Hintert  Ut&nosmzm^. 


Ghe^rf louche  des 
I'umcrs 

lEiZeiten 


Ei.erslotJ£s. 


Obe^fUiehe  d.  I.E. 


SchmJtflUcJte  d.7tcl}t&n> 
Eicrstc^Cs. 


Fig.  219. — Fibroma  affecting  both  ovaries  (Winckel). 

prove  fatal  except  by  indirect  effects.  It  is  rare,  and  hence  not  of 
sufficient  importance  to  demand  a  separate  class  for  itself  alone.  In 
describing  this  form  of  neoplasm  I  may  say  that  it  is  like  the  cysto- 
fibronia,  minus  the  cyst  or  cysts.  The  composition  of  the  growth  is 
similar  to  that  of  the  fibroid  tumors  of  the  uterus.  That  the  fibroma 
of  the  ovary  is  very  closely  related  to  the  cysto-fibroma.  is  further 
shown  from  the  fact  that  so-called  fibromata  have  been  found  with 
small  cysts.  In  the  one  the  cyst  element  predominates,  while  in  the 
other  the  solid  or  fibrous  element  is  the  principal  or  onlv  one  found. 
34 


514  DISEASES   OF   WOMEN. 

Cyst-Wall. — The  walls  of  the  cysts  of  ovarian  tumors  are,  as  a 
rule,  nearly  all  the  same.  For  convenience  of  description  and  for 
the  purposes  of  the  surgeon  the  wall  is  divided  into  three  layers. 
Tlie  external  is  a  serous  membrane  corresponding  to  the  peritonaeum, 
which  it  is  in  fact.  The  middle  coat  is  areolar  tissue,  and  contains 
the  main  Ijlood-vessels  of  the  cyst.  The  internal  layer  is  like  the 
external,  so  far  as  its  fibrous  elements  are  concerned,  but  it  is  really 
a  mucous  meml)rane.  It  is  less  uniform  than  the  other  layers  in 
appearance,  and  usually  contains  small  cysts  in  process  of  develop- 
ment, or  follicles  which  have  undergone  degeneration.  PapilUe  are 
often  found  developed  on  this  layer,  as  already  stated.  "While  this 
in  a  general  way  describes  the  cyst-walls,  they  are  subject  to  certain 
modifications,  as  follows :  The  middle  layer,  which  is  well  defined  at 
the  base  of  the  tumor,  contains  the  large  vessels,  and  is  easily  sepa- 
rated from  the  peritoneal  layer.  It  becomes  thinner  the  farthei-  it 
departs  from  the  pedicle,  and  when  it  reaches  about  the  middle  of 
the  tumor  there  are  only  two  layers  easily  distinguished,  while  at 
the  sununit  there  is  only  one  that  can  be  made  out  by  ordinary  dis- 
section. 

While  the  middle  layer  diminishes  gradually'  as  it  gets  farther 
and  farther  away  from  the  base  and  finally  disappears,  the  internal 
and  external  layers  come  together  and  are  united,  and  increase  in 
thickness  so  that  the  cyst-wall  becomes  a  fibrous  homogeneous  mem- 
brane. Some  authors  have  made  more  minute  sul>di visions  of  the 
layers  of  the  cyst-wall,  but  that  I  look  ujion  as  a  super- refinement  in 
dissection  which  has  no  value  in  this  connection. 

The  outer  and  iimer  coats  are  often  modified  in  appearance  and 
character.  The  external  layei-  is  changed  in  places  by  circuinscril)ed 
peritonitis,  or  by  great  vascularity,  and  the  internal  coat  is  often 
changed  l)y  intlannnatory  action,  degeneration,  or  liv|)erplasia. 

The  appearance  of  the  outer  coat  has  a  special  interest  for  the 
surgeon.  To  l)e  able  to  recognize  the  cyst-wall  when  one  comes  to 
it  in  operating  is  very  important.  Many  times,  in  sim])le  uncomjtli- 
cated  cases,  the  cyst-wall  is  smooth,  of  a  whitish  color,  slightly  tinged 
with  a  pinkish,  pearly  tint  which  resembles  the  ])eriton;eum,  evei'v- 
where  covering  the  abdominal  viscera,  and  yet  easily  distinguished. 
Wlien  there  has  been  peritonitis,  the  cyst-wall  becomes  covered  with 
lymph  or  adhesions,  and  so  changed  in  a])pearance  that  it  is  ditfieult 
to  recognize  it  when  it  is  reached,  owing  to  the  ])roducts  of  intlam- 
mation.  The  vascularity  of  the  outer  coat  of  the  cyst  varies  greatly. 
Sometimes  the  whole  surface  presi-nts  a  fine  netwoi-i<  (»f  vessels  all 
over  the  parts  that  ai'e  seen;  in  other  cases  the  vascularity  is  exag 


NEOPLASMS   OF   TIIP:   OVARIES.  515 

gerated  in  patclies.  This  great  vascularity,  M-lieii  it  occurs  Avitli- 
out  preceding  evidence  of  intiannnation,  makes  a  marked  contrast 
between  the  cyst  and  the  abdominal  viscei-a,  which  enables  one  to 
promptly  distinguish  the  one  from  the  other.  In  a  few  tumors,  all 
of  them  occurring  in  oldish  patients,  I  have  found  large  portions  of 
the  cyst- wall  of  a  pale,  grayish-white  color,  without  any  recognizaljle 
vascularity.  This  made  the  cyst  very  pecuhar  in  appearance  and 
easily  recognized.  This  rare  and  peculiar  color  is  caused  by  com- 
mencing necrosis. 

Contents  of  Ovarian  Cysts. — The  contents  of  the  simplest  variety 
of  cyst  are  a  serous  fluid  of  a  lemon  or  amber  color,  hut  subject  to 
marked  variation  in  different  cases.  The  character  of  the  fluid  is 
modified  by  the  size  of  the  cyst,  the  lengtli  of  time  it  has  existed, 
and  whether  the  cyst  has  been  tapped  ;  under  these  modifying  influ- 
ences the  fluid  may  be  colorless,  or  chocolate-colored  from  the  pres- 
ence of  blood  in  varying  quantity,  or  it  may  be  of  a  greenish-yellow 
color,  from  the  presence  of  pus  produced  by  inflammation  of  the 
cyst.  Shreds  and  flakes  of  whitish  lymph  are  sometimes  found  with 
the  pus  when  there  has  been  inflammation.  Occasionally  the  fluid 
is  viscid. 

It  generally  contains  albumen  or  paralbumen,  and  sometimes 
crystals  of  cholesterine  are  found  in  it.  The  contents  of  the  multi- 
1  ocular  cysts  resemble  those  just  described,  presenting  the  same  dif- 
ferences in  different  patients.  Usually  the  fluid  is  more  viscid  or 
gelatinous,  sometimes  quite  thick,  so  that  it  escapes  with  difficulty. 
In  one  case  I  found  the  cyst  contents  exactly  like  jelly,  but  different 
in  character  in  this,  that  jelly  is  friable,  but  this  material  was  ex- 
ceedingly tenacious,  so  that  it  could  not '  be  pressed  out  of  the  sac, 
and  was  even  pulled  out  with  the  hand  with  great  difficulty.  The 
fluid  in  the  sevei'al  cysts  of  a  multilocular  tumor  is  not  always  the 
same.  It  often  differs  in  color  and  consistency  in  the  dift'erent 
divisions  of  the  tumor.  In  addition  to  the  albumen,  blood,  choles- 
terine, pus,  and  lymph,  which  may  be  present  in  the  fluid  of  ovarian 
cysts,  there  are  other  chemical  and  anatomical  elements  found  which 
are  of  interest. 

The  contents  of  ovarian  cysts  have  l)een  most  thoroughly  investi- 
gated as  to  their  chemical  composition  by  Eichwald.  As  has  already 
been  stated,  they  may  be  as  fluid  as  serum,  or,  as  is  niore  often  the 
case,  viscid  sometimes  to  such  a  degree  as  to  be  gelatinous  in  con- 
sistency. The  specific  gravity  may  be  as  low  as  1<)07,  or  as  high  as 
1020.  There  are  two  distinct  classes  of  elements  which  occur  in 
the  contents  of  these  cysts :   the  one  mucous  in  its  nature,  which 


516  DISEASES  OF  WOMEN. 

predominates  in  the  younger  cysts;  the  other  albnminons,  whieli  is 
characteristic  of  the  large  and  older  colloid  cysts.  The  colloid  sub- 
stance is  regarded  as  a  modified  niucine  formed  from  the  substance 
of  the  colloid  bodies  and  the  parenchyma  of  the  cells  of  the  ovaries. 
Colloid  degeneration  is  therefore  but  another  name  for  mucous 
metamorphosis.  The  first  or  mucine  class  consists  of  four  ele- 
ments :  the  sul)stance  of  the  colloid  corpuscles,  mucines,  colloid 
substance,  and  muco-peptone.  These  are  distinguished  l)y  their 
solubility  in  water,  and  l)y  various  reactions  which  need  not  be 
mentioned  here. 

The  second  or  all)uminous  class  is  characterized  by  the  presence 
in  the  contents  of  the  cysts  of  free  albumen  and  the  albuminate  of 
soda.  In  colloid  tumors  the  free  albumen  ]>ecomes  albuminoid  ])ep- 
tone,  while  the  albuminate  undergoes  no  change.  The  conversion 
of  free  albumen  takes  place  slowly ;  it  first  becomes  paralbumen, 
then  metall)umen.  These  are  not  fixed  bodies,  but  pass  on  to  the 
condition  of  ])eptone.  Thus,  the  albuminous  elements  which  ai'e 
found  in  this  albuminous  class  are  albuminous  parall)umen,  metalbu- 
men,  and  albuminoid  peptone.  In  a  chemical  analysis  of  the  con- 
tents of  a  cyst,  Eichwald  found  the  following  to  be  its  composition: 

Water 931.96 

Organic  substances 59.77 

Potass,  sulph .08 

"       chlor 59 

Sod.  nit   6.29 

"     phosi)h 16 

"     carb 38 

Salts  insoluble  in  water .74 

Loss 03 

Ktod.oo 

MICROSCOPIC    CONTENTS    OF    OVARIAN    CYSTS. 

Under  tlie  microscope  the  contents  of  different  cysts  present  very 
different  appearances.  The  cell  elements  al)ouii(l  in  those  which  are 
colloid  in  their  nature,  while  those  which  are  serous  are  very  defi- 
cient in  this  res])ect.  Eichwald,  in  one  of  the  colloid  cysts,  found 
so  large  an  amount  of  corpuscular  elements  that  he  was  unable  to 
examine  it  satisfactorily  with  the  microscoj)e  until  he  liad  diluted  it 
with  water.  When  thus  treated  he  found  fatty  elements,  round  and 
serrated  cells,  large  colloid  cells,  round  cells  i-esem])ling  those  de- 
scribed by  Lebert  as  jnoid  Imdies,  and  i)y  llenle  as  exudation  cor])Us- 


NEOPLASMS   OF   THE   OVARIES.  517 

cles ;  globular  aggregations  of  various  sizes,  scales  of  eijitlieliuni, 
crystals  of  cliolesterine,  and  brown  pigment  were  also  found.  As  a 
rule,  the  morphological  elements  found  in  the  fluid  of  ovarian  cysts 
are  granular  cells,  free  granules,  small  oil-globules,  epithelial  cells, 
blood-corpuscles,  Gluge's  corpuscles,  and  pus  cells.  From  time  to 
time  various  cells  have  been  described  as  characteristic  of  the  ovarian 
cyst.  Among  others,  Drysdale  has  described  such  a  cell,  which  he 
speaks  of  as  "•  the  ovarian  granular  cell,"  and  which  he  regards  as 
pathognomonic  of  ovarian  disease.  His  claim  to  the  discovery  of 
this  cell  is  thus  put :  "  I  claim,  then,  that  a  granular  cell  has  been 
discovered  by  me  in  ovarian  fluid,  which  differs  in  its  behavior  with 
acetic  acid  and  ether  from  any  other  known  granular  cell  found  in 
the  abdominal  cavity,  and  which,  by  means  of  these  reagents,  can  be 
readily  recognized  as  the  cell  that  has  been  described ;  and,  further, 
that  by  the  use  of  the  microscope,  assisted  by  these  tests,  we  may 
distinguish  the  fluid  from  ovarian  cysts  from  all  other  abdominal 
dropsical  fluids." 

This  "  ovarian  granular  cell "  of  Drysdale  is  generally  round, 
but  sometimes  oval,  is  very  delicate  and  transparent,  and  contains  a 
number  of  fine  granules,  but  no  nucleus.  The  size  of  the  cell  varies 
from  y.oVo'  ^^ich  to  g.-oVo  ii^ch.  When  acetic  acid  is  brought  in 
contact  with  this  cell  it  becomes  more  transparent,  and  its  granules 
appear  more  distinct.  On  the  other  hand,  when  thus  treated  with 
acetic  acid  it  becomes  larger,  and  from  one  to  four  nuclei  appear. 
It  is  distinguished  from  Gluge's  inflammation  corpuscle  by  the  fact 
that,  when  ether  is  added,  the  ovarian  cell  is  unaft'ected — at  most, 
has  its  granules  made  paler ;  while  Gluge's  corpuscle  loses  its  granular 
appearance,  and  sometimes  entirely  disappears  through  a  solution  of 
its  contents  by  the  ether.  In  reference  to  this  subject  it  may  be  said 
that  the  views  of  Drysdale  deserve  the  most  careful  consideration, 
but  I  am  not  as  yet  satisfied  in  my  own  mind  that  this  corpuscle  is 
pathognomonic  of  ovarian  disease,  nor  indeed  that  the  diagnosis  can 
be  positively  made  by  either  chemical  or  microscopical  analysis. 

Complications. — Tliere  are  certain  ])atho]ogical  changes  which 
occasionally  occur  during  the  progress  of  an  ovarian  tumor  which 
may  be  considered  as  complications  of  the  original  affection.  The 
presence  of  an  ovarian  tumor  tends  to  excite  circumscribed  inflam- 
mation of  the  peritomieum,  which  gives  rise  to  adhesions  of  the  cyst 
or  tumor  to  the  pelvic  or  abdominal  viscera.  This  is  the  most  fre- 
cpient  complication,  and  one  which  is  of  exceeding  interest  to  the 
surgeon.  The  location,  extent,  and  firmness  of  the  adhesions  differ 
greatly  according  to  the  duration,  size,  and  character  of  the  cyst  or 


518  DISEASES  OF  WOMEN. 

tumor.  It  is  also  possible  tiiat  the  state  of  the  patient's  constitution 
and  general  health  may  have  some  influence  in  determining  the 
development  of  inflammatory  adhesions.  In  regard  to  the  effect 
wliich  the  nature  of  the  tumor  has  upon  the  occurrence  of  adhesions 
my  observations  lead  me  to  believe  that  malignant  growths  and 
those  that  are  mixed — that  is,  in  part  benign  and  in  part  malignant 
— are  most  frequently  found  to  have  adhesions.  It  is  also  a  ques- 
tion whether  the  adhesions  found  by  some  of  these  neoplasms  result 
in  all  cases  from  peritoneal  inflammation.  In  some  cases  that  I 
have  seen  it  appeared  to  me  that  the  ovarian  tumor  became  attached 
to  the  viscera  in  contact  with  it  by  an  extension  of  the  ovarian  dis- 
ease. It  may  be  that  in  such  cases  the  malignant  disease  may  have 
begun  in  other  organs  and  tissues  as  well  as  in  the  ovary,  and  that 
the  diseased  parts  became  united  without  intervening  products  of 
inflammation  ;  occasionally  adhesions  occur  where  the  tumor  is  small, 
and  then  they  are  found  in  the  pelvis  or  in  relation  with  the  lower 
intestines.  When  they  take  place  after  the  tumor  is  large  enough 
to  distend  the  abdominal  walls  they  are  found  higher  up.  Then  the 
tumor  may  be  adherent  to  the  abdominal  wall,  omentum,  stomach, 
loin,  diaphragm,  or  to  the  lumbar  region.  Such  extensive  adhesions 
are  rather  rare,  still  they  occur  sufficiently  often  to  be  of  the  great- 
est interest  to  the  surgeon.  These  adhesions  sometimes  displace  the 
pelvic  organs  and  derange  their  functions.  When  a  small  tumor 
becomes  adherent  to  the  uterus  or  bladder  it  will  carry  these  organs 
up  out  of  place  when  it  grows  larger  and  rises  up  into  the  abdominal 
cavity. 

Obstruction  of  the  intestines  may  be  caused  by  the  traction  of 
adhesions  and  also  by  the  pressure  of  a  very  large  tumor.  Occasion- 
ally a  small  tumor  in  the  pelvis  may  make  pressure  upon  the  rectum 
sufficient  to  obstruct  the  action  of  the  bowels,  but  that  is  rather  rare, 
unless  the  tumor  is  so  firmly  fixed  by  adhesion  that  it  can  not  be  dis- 
lodged. Rotation  of  the  tumor  upon  its  axis  occasionally  takes  place. 
This  produces  twisting  of  the  pedicle  and  partial  or  complete  stran- 
gulation of  the  blood-vessels  and  tissues  of  the  pedicles.  The  result 
is  that  the  blood  can  not  return  from  the  tumor,  and  hence  the  ves- 
sels become  overdistended  and  sometimes  rupture  follows.  The 
bleeding  into  the  cyst  suddenly  distends  it  and  causes  shock.  Some- 
times the  cyst  ruptures  under  the  pressure  of  the  haemorrhage  with- 
in it  and  death  may  fake  place.  Cases  have  been  known  of  haemor- 
rhage into  the  cyst  which  have  proved  fatal  from  shock  and  loss  of 
blood  without  the  cyst  bursting.  Should  the  patient  withstand  the 
shock  and  haemorrhage,  peritonitis  and  cystitis  are  likely  to  occur. 


NEOPLASMS   OF   THE   OVARIES.  519 

Death  takes  place  as  a  rule,  if  the  twistmg  of  the  pedicle  is  suffi- 
cient to  completely  arrest  the  circulation.  This  proves  fatal  unless 
the  tumor  is  removed.  If  the  twisting  is  not  sufficiently  marked  to 
arrest  the  nutrition  of  the  tumor  suddenly  and  completely  atrophy 
may  take  place  instead  of  gangrene  or  necrosis.  Spontaneous  cure 
has  taken  place  in  this  way,  the  tumor  shriveling  up  and  disappear- 
ing. Some  very  curious  things  have  happened  from  tv^isting  of  the 
pedicle.  Atrophy  has  taken  place  so  perfectly  that  the  pedicle  has 
been  severed,  the  tumor  becoming  entirely  free  from  all  attach- 
ments. 

More  strange  things  still  have  happened.  The  tumor  has  be- 
come adherent  to  some  part  of  the  abdominal  viscera  and  subse- 
quently the  pedicle  has  become  separated  from  the  tumor  by  a  pro- 
cess of  slow  atrophy.  While  the  separation  of  the  pedicle  is  slowly 
disappearing  the  vascularity  increases  at  the  point  of  adhesion,  and 
the  tumor  derives  its  nourishment  from  its  new  attachment.  This 
has  been  described  as  transplantation,  a  term  which  clearly  indicates 
the  process  which  takes  place. 

Dragging  of  the  Pedicle  gives  results  similar  to  twisting.  This 
dragging  is  produced  usually  when  pregnancy  occurs  during  the  ex- 
istence of  an  ovarian  tumor.  The  uterus  growing  faster  than  the 
pedicle  pushes  the  tumor  upward  and  makes  strong  and  continuous 
traction  upon  the  pedicle  and  obstructs  the  vessels.  Again,  if  the 
ovary  is  adherent  in  the  pelvis,  and  the  pregnant  uterus  ascends, 
traction  will  be  made  sufficient  to  damage  the  nutrition  of  the  ovary 
and  any  cyst  that  may  exist  there.  There  is  another  way  in  which 
traction  of  the  pedicle  may  occur.  A  cyst  or  tumor  may  be  carried 
high  up  in  the  abdomen  with  the  pregnant  uterus,  and  become 
adherent  at  its  higher  part,  and  when  the  uterus  descends  after 
delivery  the  pedicle  may  become  stretched.  It  is  presumed  that 
cystic  tumors  may  become  atrophied  and  a  spontaneous  recovery  oc- 
cur. This  belief  is  based  upon  the  fact  that  in  old  women  the  ova- 
ries have  been  found  to  contain  shrunken  cysts  imbedded  in  very 
hard,  thickened  stroma  and  it  is  believed  that  this  condition  is  the 
result  of  atrophy  by  cystic  tumors.  There  is  no  absolute  proof  that 
absorption  of  the  fluid  and  shriveling  of  the  cyst-wall  occurs  except 
by  obstruction  of  the  blood-vessels  in  the  pedicle  as  already  de- 
scribed. 

Rupture  and  Perforation  of  Ovarian  Cysts. — Rupture  may  occur  as 
the  result  of  overdistention  of  the  cyst-wall  from  rapid  accumula- 
tion of  fluid  in  the  cyst,  or  from  injuries  such  as  direct  blows  or 
concussions   from  fallinoj  or  sudden  exertion.     The  bursting  of  a 


520  DISEASES   OF   WOMEN. 

cyst  may  cause  death,  or  the  opening  may  be  closed  by  inflamma- 
tory exudation  and  the  cyst  retilh  It  has  also  been  claimed  that  the 
cyst  may  disappear,  and  the  patient  recover.  When  this  spontane- 
ous recovery  occurs  after  the  bm'sting  of  a  cyst,  there  is  always 
room  for  doubt  about  its  being  an  ovarian  cyst.  For  the  present 
it  must  remain  an  open  question  whether  ovarian  cysts  ever  disap- 
pear in  this  way.  It  is,  however,  well  known  that  cysts  of  the 
ovary  frequently  burst  and  empty  their  contents  into  the  abdominal 
cavity.  The  results  of  tliis  differ  greatly ;  sometimes  there  is  not 
much  trouble  if  the  fluid  is  clear  and  non-irritating ;  in  other  cases 
death  is  caused  in  a  short  time  by  shock,  or  peritonitis  may  follow 
and  cause  death  or  terminate  in  closing  the  opening  in  the  cyst  and 
forming  extensive  adhesions  of  the  cyst-  and  abdominal-walls  and 
viscera.  In  those  cases  which  recover  from  the  shock  of  rupture 
and  the  subsequent  peritonitis  and  the  cysts  reflll  there  are  always 
extensive  adhesions  found. 

Perforation  differs  from  rupture  in  being  a  slow  process  and  in 
the  fact  that  the  opening  is  frequently  into  the  adjoining  viscera  of 
the  abdomen  or  pelvis.  There  are  two  ways  in  which  perforations 
occur ;  the  one  by  thinning  of  the  cyst-wall  from  pressure,  either 
from  within  the  cyst  or  from  without  at  a  given  point,  and  the  other 
and  most  frequent  by  suppuration  or  ulceration.  Perforation  occur- 
ring in  either  way  may  open  into  the  peritonaeum,  but  in  case  the 
opening  is  the  result  of  suppuration  it  may  be  into  some  of  the 
neighljoring  organs.  In  some  cases  the  perforation  is  very  small 
and  the  opening  is  closed  by  exudations  which  also  form  adhesions 
to  the  neighboring  organs.  This  fact  has  led  to  the  behef  tliat 
many  of  the  adhesions  found  are  the  result  of  these  small  perfoi-a- 
tions  which  admit  of  a  limited  escape  of  the  cyst  fluid.  Should  the 
perforation  bo  large  a  free  escape  of  the  fluid  may  take  place,  and 
the  result  would  be  the  same  as  in  case  of  rupture.  When  the  per- 
foration is  into  the  intestine,  the  contents  of  the  sac  may  be  wholly 
emptied,  but  this  form  of  perforation  is  rare. 

Another  rare  form  of  perforation  has  been  seen  in  which  a 
communication  between  an  ovarian  cyst  was  formed  by  ulceration 
extending  from  the  intestine  and  opening  into  the  cyst. 

Ovarian  Cystitis. — Inflammation  of  the  interior  of  the  cyst  occurs 
occasicjnally  and  is  a  serious  complication.  In  multiple  and  nmlti- 
locular  cysts  the  inflammation  is  usually  limited  to  one  or  more  of 
the  cysts,  the  others  in  the  tumor  remaining  in  their  original  condi- 
tion. The  inflammati<jn  is  of  a  low  form  in  most  cases  and  ends  in 
8up|)uration ;  in  others  tiiere  is  a  mixture  of  pus  with  shreds  and 


NEOPLASMS   OF  THE   OVARIES.  521 

flakes  of  lymph.  The  original  fluid  in  tlie  cyst  is  supplanted  to  a 
large  extent  by  these  products  of  inflammation. 

This  was  well  illustrated  in  a  case  of  a  monocyst  which  came  un- 
der my  care  years  ago.  I  tapped  the  cyst,  and  withdrew  a  half  a 
pint  of  clear  fluid,  inflammation  followed,  and  the  cyst  slowly  tilled 
up  but  did  not  increase  beyond  its  original  size.  It  became  adher- 
ent to  the  abdominal  wall  and  Anally  opened  externally,  and  it  was 
then  found  to  be  filled  with  pus. 

In  another  case  a  hypodermic  syringe  full  of  clear  fluid  was 
drawn  off  from  the  major  cyst  of  an  ovarian  tumor,  and  then  inflam- 
mation followed,  and  the  patient  was  subsequently  brought  to  me 
for  operation.  I  found  pus  and  lymph  in  the  cyst,  but  the  most  of 
the  original  clear  fluid  had  disappeared. 

Abdominal  dropsy  is  still  another  complication  which  may  occur. 
There  is  in  many  cases  a  little  free  fluid  in  the  peritoneal  cavity 
which  is  not  of  special  interest,  but  in  other  cases  the  quantity  of 
fluid  is  such  that  it  may  in  bulk  exceed  that  of  the  ovarian  tumor. 
This  is  more  likely  to  occur  in  malignant  growths  and  in  papillary 
ovarian  cysts.  This  will  be  referred  to  again  while  discussing  diag- 
nosis and  treatment. 

There  are  many  local  and  constitutional  conditions  which  may 
be  found  accompanying  ovarian  tumors,  but  those  complications 
which  can  be  rationally  considered  as  resulting  from  the  affection  of 
the  ovary  have  been  mentioned. 


ClIAPTEll   XXVIII. 

CYSTIC    TUMORS    OF    THE    OVARIES — SYMPTOMATOLOGY    AND    PHYSICAL 

SIGNS. 

The  most  peculiar  feature  in  the  clinical  history  of  this  variety 
of  ovarian  tumor  is  the  fact  that  subjective  symptoms  are  often  ab- 
sent. Cases  are  sometimes  seen  in  which  the  patient  is  unconscious 
of  anything  being  wrong  until  the  tumor  becomes  noticeable  by 
the  increased  size  of  the  abdomen.  It  is  equally  strange  that  the 
tumor  is  often  unobserved  by  the  patient  until  it  has  attained  a  con- 
siderable size.  But,  while  cases  occur  without  noticeable  symptoms, 
the  majority  of  patients  suffer  from  some  pain  and  discomfort,  and 
at  the  same  time  there  is  more  or  less  derangement  of  the  function 
of  the  ovaries,  and  occasionally  some  disturbance  of  neighboring 
organs.  The  symptoms  differ  in  the  different  stages  of  the  growth 
of  the  tumor.  I  will,  therefore,  take  up  the  three  stages  in  order. 
In  the  iirst  stage,  while  the  tumor  still  occupies  the  pelvic  cavity, 
the  patient  may  have  a  feeling  of  fullness  in  the  pelvis,  and  pos- 
sibly some  pelvic  tenesmus  on  standing  or  walking ;  pain  is  also 
present  in  the  affected  side.  The  severity  of  the  pain  differs  great- 
ly in  different  cases.  In  some  it  is  only  sufficient  to  attract  the 
attention  of  the  patient  at  times,  but  is  not  acute  enough  to  pre- 
vent her  from  performing  her  ordinary  duties.  In  others  it  is 
quite  severe,  and  accompanied  with  well-defined  tenderness,  dis- 
abling the  ]xatient  to  some  extent.  These  symptoms  may  or  may 
not  be  continuous.  The  pain  may  be  at  times  very  slight  for  days 
or  weeks,  then  increase,  and  again  subside,  and  yet  at  no  time  be 
sufficiently  marked  to  cause  the  sufferer  to  seek  advice,  and  its  ex- 
istence is  only  brought  out  by  interrogation  at  a  more  advanced 
stage  of  the  affection.  When  the  pain  is  acute  and  sufficient  to  dis- 
able the  patient,  there  is  usually  soinc  local  inflammation  to  account 
for  it.  When  such  is  the  case,  there  is  ordinarily  some  constitutional 
disturbance  indicative  of  the  local  affection.     In  quite  a  number  of 

522 


CYSTIC  TUMORS   OF  THE   OVARIES.  523 

cases  there  is  pain  for  a  few  days  at  or  just  before  the  menstrnal 
period,  or  it  may  be  midway  between  the  periods. 

The  pain  is  in  the  affected  ovary,  and  is  often  of  that  character 
which  is  called  ovarian.  It  has  been  supposed  that  this  kind  of  in- 
termittent pain  is  due  to  ovulation,  occurring  in  the  morbid  ovary. 
When  the  pain  occurs  in  the  intra-menstrual  period,  it  is  presumed 
to  be  caused  by  some  trouble  during  the  maturation  of  the  ovule ; 
and,  when  it  comes  on  about  the  menstrual  period,  it  is  due  to  the 
process  of  rupture  of  the  Graafian  vesicle.  Menstruation  is  fre- 
quently deranged,  bnt  not  always.  While  one  ovary  is  affected, 
the  other  may  be  normal,  and,  so  far  as  the  ovaries  influence  men- 
struation, there  is  no  change,  and  the  uterine  function  goes  on  in 
the  usual  way.  This  is  sometimes  the  case  when  both  ovaries  are 
affected.  It  would  appear  that,  while  a  part  of  the  ovaries  is  mor- 
bid, there  still  remains  enough  that  is  normal  to  perform  the  func- 
tion and  maintain  the  ovarian  influence  upon  menstruation.  It 
frequently  happens,  however,  that  menstruation  is  deranged  dur- 
ing the  existence  of  ovarian  tumors.  As  already  stated,  there  may 
be  pain  at  the  menstrual  period,  which  is  easily  mistaken  for  dys- 
menorrhcea.  Irregularity  or  suppression  of  the  menses  is,  I  believe, 
the  most  common  derangement.  Profuse  and  too  frequent  men- 
struation occasionally  occurs,  but  either  of  these  derangements  may 
be  due  to  some  constitutional  condition  or  some  uterine  affection, 
which  may  accompany  the  ovarian  tumor.  When  the  ovarian  tumor 
attains  considerable  size,  and  is  yet  not  large  enough  to  rise  out  of 
the  pelvis,  it  may  cause  displacement  of  the  uterus  or  bladder,  and 
give  rise  to  symptoms  peculiar  to  this  displacement.  It  is  not  often 
that  these  cause  sufficient  suffering  to  lead  the  patient  to  seek  reHef 
at  the  hands  of  the  gynecologist.  When  the  left  ovary  is  the  sub- 
ject of  the  morbid  growth,  there  is,  in  some  cases,  slight  obstruction 
of  the  rectum,  which  causes  disturbance  in  the  action  of  the  bowels. 

The  important  fact  still  remains  that,  in  the  first  stage  of  cystic 
tumors  of  the  ovaries  that  are  uncomplicated,  the  symptoms  are  often 
so  mild  that  the  patient  may  not  come  under  the  care  of  the  medical 
attendant,  and,  if  she  does,  the  symptoms  do  not  afford  any  reliable 
guide  to  the  nature  of  the  affection. 

In  short,  there  is  nothing  diagnostic  in  the  symptomatology  of 
this  stage  of  ovarian  tumors. 

In  the  second  stage,  an  enlargement  of  the  abdomen  is  noticed 
sooner  or  later  by  the  patient.  If  the  pedicle  is  short,  the  enlarge- 
ment may  be  on  one  side ;  usually  it  is  central,  or  nearly  so,  when 
first  noticed.     Here,  again,   there  are  no  other  very  well-marked 


524  DISEASES  OF   WOMEN. 

symptoms.  As  the  tumor  increases,  the  weight  and  pressure  cause 
discomfort.  This  is  hkely  to  be  felt  earher  in  those  who  have  not 
borne  children  tlian  in  those  wlio  have.  In  such  patients  the  ab- 
dominal muscles  do  not  yield  so  readily  to  accommodate  the  tumor. 
Slight  pains  recurring  at  intervals  and  tenderness  are  common  symp- 
toms, and  are  usually  due  to  tension  of  the  cystic  walls  from  increase 
of  the  contents.  When  such  pains  occur,  the  tension  of  the  cyst  is 
marked,  and  the  pain  subsides  when  the  cyst  becomes  flaccid.  If 
inflammation  of  the  cyst  oi-  portions  of  the  peritonasum  occurs,  there 
are,  in  addition  to  pain  and  tenderness,  some  constitutional  symp- 
toms, such  as  fever,  rigors,  and,  if  the  inflammation  is  extensive, 
deranged  digestion,  loss  of  flesh,  and  hectic  may  follow.  These 
symptoms  are  relied  upon  as  indicating  inflammation,  which  will 
produce  adhesions,  especially  if  the  peritonieeum  is  involved ;  but 
it  should  be  borne  in  mind  that  quite  extensive  adhesions  may  take 
place  w^ithout  their  having  been  at  any  time  well- defined  symptoms 
of  circumscribed  peritonitis.  Ordinarily,  these  are  all  the  symptoms 
manifested  in  the  second  stage. 

In  the  third  stage,  when  the  tumor  begins  to  make  strong  press- 
ure upon  the  different  v^iscera,  another  class  of  symptoms  appears. 
These  were  hinted  at  while  discussing  the  growth  of  ovarian  tumors. 
Deranged  digestion  and  imjiaired  micturition,  diflicult  breathing, 
distressing  weight,  and  a  dragging  on  the  abdominal  muscles,  to- 
gether with  pain  and  tenderness,  may  all  supervene.  Some  of  the 
symptoms  which  characterize  the  flrst  stage,  and  disappear  in  the 
second,  often  recur  in  the  third.  Pressure  on  the  bladder  may  cause 
frequent  urination,  and  the  bowels  may  become  obstinately  consti- 
pated. Paroxysms  of  pain  in  the  limbs  and  abdomen  may  be  very 
severe,  caused  by  oljstructed  circulation.  From  the  same  cause  ef- 
fusion of  fluid  into  the  abdominal  cavity  and  redema  of  the  legs  may 
occur. 

The  patient  becomes  emaciated,  weak,  and  sometimes  hectic,  but 
not,  as  a  rule,  cachectic  in  the  benign  forms  of  ovarian  tumors. 

PJiijiilcal  Signs. — The  ])hysical  examination  of  ovarian  tumors 
is  made  ])y  the  means  generally  employed,  and  fully  described  in 
the  flrst  chai)ter  of  this  work.  They  are  inspection,  vaginal  touch, 
palpation,  percussion,  auscultation,  measurement,  exploration  by  as- 
piration, microscopical  and  chemical  examination  of  fluid  obtained  by 
aspiration,  and,  Anally,  laparotomy.  The  evidence  obtained  by  phys- 
ical exploration  dillers  in  each  stage  of  the  growth  of  ovarian  tumors. 
In  the  flrst  stage,  the  bimanual  examination  of  the  pelvic  contents 
is  all  that  is  necessary,  this  giving  all  the  information  which  can  be 


CYSTIC  TUMORS   OF  THE  OVARIES.  525 

obtained,  except  in  obscure  cases,  wliere  aspiration  may  be  advisable. 
Sometimes  it  may  be  necessary  to  pass  the  sound  into  the  uterus  to 
conlirm  or  correct  the  impressions  obtained  by  the  touch.  Occa- 
sionally, also,  when  the-parts  are  tender  and  resisting,  it  is  necessary 
to  give  an  anaesthetic  in  order  to  make  a  satisfactory  examination. 
The  method  of  searching  for  small  ovarian  cysts  in  the  pelvis  is  the 
same  as  that  recommended  in  prolapsus  of  the  ovary,  and  described 
in  a  previous  chapter.  Where  the  tumor  has  attained  any  consider- 
able size,  the  bimanual  touch  gives  the  most  satisfactory  evidence. 
The  tumor,  caught  between  the  fingers  of  the  two  hands,  can  be 
outlined,  and  its  consistence  ascertained  with  a  tolerable  degree  of 
accuracy. 

In  the  early  stage  the  cyst  is  usually  found  on  one  side  of  the 
pelvis,  or  else  in  tbe  sac  of  Douglas,  exactly  behind  the  uterus,  or 
a  little  inclined  to  one  side.  It  is  usually  soft  and  slightly  yielding 
to  the  touch,  sometimes  globular  and  smooth  of  surface,  or  else 
globular  in  the  main,  with  some  irregular  projections.  These  irregu- 
larities are  due  to  the  presence  of  small  cysts  and  the  portions  of  the 
ovary  that  remain  normal. 

The  physical  signs  obtained  by  this  examination  determine  the 
fact  that  there  is  a  neoplasm,  and  that  it  is  possibly  cystic  ;  but  there 
is  no  direct,  positive  evidence  regarding  the  structure  of  the  tumor, 
nor  that  it  is  ovarian.  In  other  words,  the  physical  signs  are  not 
diagnostic — i,  e.,  direct  and  positive.  It  is  necessary,  on  this  account, 
to  employ  the  method  of  diagnosis  by  exclusion. 

Diffe7'ential  Diagnosis  in  the  First  Stage. — There  are  many 
affections  which  may  present  symptoms  and  signs  remotely  resem- 
bling cystic  tumors  of  the  ovary.  Those  whiicli  most  nearly  approach 
them  in  character  are,  dilatation  of  the  Fallopian  tube  from  hydro- 
salpinx or  pyosalpinx,  parovarian  cysts  when  small,  extra-uterine 
pregnancy,  pregnancy  in  a  bicornute  uterus,  subperitoneal  fibroids 
of  the  uterus,  fibroid  tumor  of  the  ovary,  and  tumors  of  the  second 
class,  which  include  the  cystic  and  solid  malignant  growths,  and  in 
a  less  degree  pelvic  hematocele,  pelvic  peritonitis,  and  cellulitis. 

Fecal  accumulations  in  the  upper  part  of  the  rectum,  and  back- 
ward dislocations  of  the  uterus,  have  also  been  mentioned  as  simulat- 
ing ovarian  tumors,  but  these  can  be  so  easily  differentiated  that 
they  need  only  to  be  named.  Dilatation  of  the  Fallopian  tube  may 
be  distinguished  from  a  cystic  ovary  by  its  oblong  shape,  and  some- 
times, when  the  tube  is  low  down  in  the  sac  of  Douglas,  the  normal 
ovary  can  be  felt  above  the  tube  by  the  bimanual  touch.  In  case 
the  dilatation  of  the  tube  is  due  to  pyosalpinx,  the  history  will  tell 


526  DISEASES   OF   WOMEN. 

of  a  previous  inflammation,  and  the  constitutional  symptoms  are  usu- 
ally more  marked.  Should  it  be  necessary  to  make  an  immediate 
diagnosis,  the  tumor  may  be  aspirated,  and  the  characteristic  epithe- 
lium of  the  tube,  if  found  by  the  microscope,  will  decide  the  question. 
It  is  safer  and  surer  to  wait  and  watch  the  progress  of  the  case.  In 
time  the  ovarian  tumors  will  grow  and  rise  out  of  the  pelvis,  while 
in  case  of  a  dilated  tube  there  will  not  be  any  great  increase  in  size, 
but  there  wiU  be  more  local  and  constitutional  disturbance.  This 
difference  in  the  progress  of  the  two  affections  is  the  most  reliable 
means  of  differentiation.  Parovarian  cysts  can  not  be  distinguished 
from  ovarian  when  they  are  small,  unless  the  ovary  can  be  separated 
from  the  cyst,  and  ascertained  to  be  normal.  Fortunately,  it  is  not 
of  great  iniportance  to  distinguish  the  one  form  of  cyst  from  the 
other  in  the  first  stage  of  their  growth.  Extra-uterine  pregnancy 
presents  physical  signs  which  can  not  always  be  distinguished  from 
those  of  ovarian  tumors,  and  in  both  there  is  a  gradual  increase  in 
size,  so  that  neither  the  physical  signs  nor  the  progress  of  the  case 
are  reliable  aids  in  diagnosis.  The  general  signs  and  symptoms  are 
usually  sufficient  to  decide.  In  cases  of  doubt,  the  electrical  treat- 
ment which  arrests  the  progress  of  the  gestation  should  be  tried. 
Pregnancy  in  the  uterus  bicornis  may  be  detected  by  finding  the 
other  horn  of  the  uterus,  and  perhaps  the  ovaries  may  be  found  nor- 
mal. These  conditions  are  rare,  and  will  not  frequently  come  up  as 
questions  of  diagnosis  in  ovarian  affections. 

Small,  subperitoneal  fibroids  of  the  uterus  differ  from  ovarian 
cysts  in  being  firm  to  the  touch,  and  generally  accompanied  with 
enlargement  of  the  uterus  and  menorrhagia.  They  are,  when  small, 
usually  united  closely  to  the  uterus.  An  ovarian  cyst  is  likely  to 
be  mistaken  for  a  fibroid  of  the  uterus  when  it  is  very  tense  and 
adherent  to  the  uterus  by  inflammatory  adhesions.  Here,  again, 
time  will  determine,  because  the  ovarian  will  grow  faster  than  the 
uterine  tumor,  and  will  show  its  characteristics  more  clearly  the 
larger  it  grows.  A  fibroid  tumor  of  the  ovary  can  not  be  distin- 
guished from  a  tense  ovarian  cyst  or  a  fibro-cyst  of  the  ovary  in  all 
cases  by  physical  signs,  but  the  history  will  help  materially  in  mak- 
ing a  diagnosis,  and,  when  the  fibroid  becomes  large  enough  to  rise 
out  of  the  pelvis,  its  solid  character  will  be  easily  made  out. 

Neither  can  a  fibrocyst  of  the  ovary  be  distinguished  from  a 
multiple  cystic  tumor  in  which  the  cyst-walls  are  very  thick.  But 
the  diagnosis  of  the  exact  composition  of  such  tumors  is  not  of  any 
practical  importance  in  relation  to  treatment. 

From  what  has  been  said  it  will  be  seen  that  the  question  to  be 


CYtSTlC   TUMOKS   OF   THE   OVARIES.  527 

decided  is,  Whether  the  tumor  found  in  the  pelvis  is  ovarian  or  not ; 
and,  when  that  is  settled,  the  next  question  which  arises  is,  Wliat  is 
the  nature  of  the  tumor?  If  it  can  be  determined  that  the  tumor 
belongs  to  the  first  class  of  ovarian  neoplasms,  tliat  will  suffice  for 
such  cases.  It  is  otherwise  in  tumors  of  the  second  class,  because 
in  malignant  affections  it  is  important  to  make  a  diagnosis  early.  If 
the  tumor  is  of  the  first  class,  no  harm  can  come  from  waiting,  Mdiile, 
if  it  is  of  the  second,  surgical  interference  may  be  necessary  while 
the  tumor  is  yet  small.  The  physical  signs  of  malignant  ovarian 
tumors  will  be  spoken  of  in  another  chapter,  but  I  may  briefly  state 
here  that  the  density  and  irregularity  of  outline,  so  commonly  found 
in  malignant  disease  elsewhere,  are  wanting  in  the  cystic  tumors  of 
the  ovary.  The  constitutional  disturbances  are  usually  developed 
early  in  malignant  diseases,  while  it  is  otherwise  in  the  benign 
forms. 

Pelvic  hematocele,  pelvic  peritonitis  and  cellulitis  may,  after  the 
acute  stage  of  these  affections  has  subsided,  present  certain  physical 
signs,  which  may  lead  one  to  suspect  an  ovarian  cystic  tumor.  But 
the  history  of  such  affections  will  put  the  diagnostician  on  his  guard, 
so  that  time  may  be  given  to  see  whether  the  tumor  which  has  been 
discovered  grows,  as  it  will  do  if  it  is  a  cystic  ovary,  except  in  rare 
cases  of  an  ovarian  cyst  arrested  in  its  growth  by  inflammation  or 
other  causes. 

Differential  Diagnosis  in  the  Second  and  Third  Stages. — By 
the  time  that  such  a  tumor  has  escaped  from  the  pelvic  to  the  abdom- 
inal cavity,  and  attracts  attention  by  its  presence  there,  it  will  have 
attained  a  size  equal  to  that  of  the  gravid  uterus  at  the  fifth  month 
of  gestation.  In  patients  of  spare  habit  it  might  be  noticed  sooner, 
but  quite  as  often  it  escapes  notice  until  a  much  later  period.  The 
physical  signs  which  are  of  most  value  to  the  diagnostician  in  the 
second  stage  are  enlargement  of  the  abdomen,  especially  of  the  lower 
portion ;  some  irregularity  in  the  form  of  the  abdomen,  one  side 
being  larger  than  the  other,  and  the  lower  being  larger  proportion- 
ately than  the  upper ;  the  tumor  is  well  defined  and  movable  in  the 
cavity  of  the  abdomen,  most  freely  from  side  to  side.  It  is  elastic 
and  fluctuating,  the  fluctuation  extending  through  the  whole  tumor 
if  a  mono-cyst,  Avhile,  if  a  multiple  cystic  tumor,  the  fluctuation  may 
be  limited  to  sections  of  the  tumor.  The  tumor  does  not  change  its 
form  to  any  extent  when  the  position  of  the  patient  is  changed, 
neither  does  the  form  of  the  abdomen  change.  It  is  attached  to  the 
pelvic  organs,  and  if  drawn  upward  will  drag  the  broad  ligament 
with  it.     The  gross  and  microscopic  appearances  and  chemical  com- 


528  DISEASES  OF   WOMEN. 

position  of  the  fluid  obtained  by  aspiration  are  also  to  be  regarded. 
Tlie  contents  of  the  cyst  are  characteristic  to  some  extent  of  the 
affection,  as  is  also  the  appearance  of  the  cyst  as  seen  after  opening 
the  abdomen.     The  physical  signs  are  very  few,  and  none  of  them 


Fig.  220. — Area  of  dullness  in  a  laigc  uviiiiiui  tmnui.     Tluic  sliDuld  be  no  sharp  lower 
limit.     The  shaded  crescent  above  represents  liver  dullness. 

alone  is  diagnostic.  In  fact,  each  of  them  may  be  found  in  otiier 
conditions  than  cystic  ovarian  tumors ;  hence  arises  the  dithculty  of 
making  a  diagnosis.  The  signs  and  the  means  of  detecting  them 
may  nx)w  be  discussed. 

By  inspection  the  increased  size  of  the  abdomen  is  detected.     In 


CYSTIC  TUMORS  OF  THE   OVARIES.  529 

the  second  stage  tliis  is  most  marked  at  tlie  lower  portion.  The  in- 
crease in  size  may  be  uniform,  tlie  two  sides  being  ahke,  or  one  side 
may  be  larger  than  the  other,  and  in  some  cases  there  is  an  irregu- 
larity of  outline  of  the  tumor  which  gives  a  nodular  appearance  upon 


Fig.  221. — Area  of  dullness  in  ascites,  indicated  by  shaded  portion  running  up  to  the  liver 
dullness.    The  tympanitic  note  about  the  navel  is  due  to  the  floating  of  the  intestines. 

inspection,  and  which  is  also  apparent  to  the  touch.  A  tumor  large 
enough  to  be  noticeable  in  the  abdomen  is  usually  in  the  center,  and 
when  it  is  eccentric  it  is  because  of  adhesions,  as  a  rule. 

The  irregular  outline  or  nodular  appearance  is  indicative  of  a 
multiple  or  multilocular  tumor.     By  palpation  the  tumor  can  usually 


530  DISEASES  OF   WOMEN. 

be  distinctly  outlined.  This  is  always  the  case,  unless  the  tumor  is 
very  flaccid  and  there  is  much  fat  in  the  abdominal  walls,  or  the 
bowels  are  distended,  but  it  is  rare  that  these  two  conditions  are 
found  together.  By  grasping  the  tumor  in  both  hands,  it  can  be 
moved  from  side  to  side  in  the  abdominal  cavity.  It  can  be  felt 
slidinof  about  under  the  abdominal  walls.  When  there  are  extensive 
adhesions,  this  valuable  sign,  mobility,  is  wanting.  By  inspection 
the  mobility  may  be  detected  by  causing  the  patient  to  take  deep 
inspirations  and  expirations,  which  will  cause  the  tumor  to  move  np 
and  down  beneath  the  abdominal  walls.  This  movement  will  be 
absent  if  there  are  adhesions. 

The  vaginal  touch  may  detect  a  portion  of  the  tumor  in  the  pel- 
vis, or  may  show  that  the  round  globular  mass  rests  on  the  pelvic 
brim.  The  uterus  can  be  made  out,  in  a  large  number  of  cases,  as 
normal,  and  not  directly  connected  with  the  tumor,  although  it  may 
be  displaced.  Beyond  this  the  touch  per  vaginam  only  gives  valu- 
able negative  evidence.  Palpation  also  shows  that  the  tumor  is 
clearly  outlined  and  easily  distinguished  from  the  neighboring  or- 
gans in  some  cases.  When  the  cyst  is  tense  the  tumor  can  be  easily 
outlined,  but  when  flaccid,  as  often  occurs,  it  is  not  by  any  means 
easy  to  map  out  its  boundaries.  Percussion  assists  in  outlining  the 
tumor  when  it  is  not  clearly  defined  to  the  touch.  The  flatness  on 
percussion  over  the  tumor  contrasted  with  the  tympanitic  resonance 
of  the  intestines,  will  indicate  its  size  and  position. 

The  consistence  can  be  determined  by  palpation,  whether  solid 
and  very  hard,  solid  and  soft,  or  fluid  and  fluctuating.  Fluctuation, 
as  a  sign  of  encysted  fluid,  may  be  obtained  in  several  ways.  If  the 
tumor  is  a  monocyst  and  is  large  enough  to  touch  the  walls  of  the 
abdomen  on  both  sides,  diametrical  fluctuation  can  be  obtained  by 
placing  the  fingers  upon  one  side  and  percussing  diametrically  op- 
posite. The  fluctuating  wave  will  be  easily  found  if  the  contents 
of  the  cyst  are  markedly  fluid.  If  the  tumor  is  divided  into  several 
sacs,  fluctuation  can  only  be  obtained  by  palpating  sections  of  it. 
Resting  the  fingers  of  one  hand  at  one  point  on  the  abdomen,  and 
percussing  at  another  point  a  little  distance  from  that  at  which  the 
fingers  rest,  a  surface  wave  will  be  produced.  In  case  the  fluid  is 
semi-solid,  and  does  not  give  the  clear  wave  on  percussion,  fluctua- 
tion may  be  produced  by  placing  the  fingers  of  both  hands  upon  the 
tumor  some  distance  apart;  then,  by  making  ])ressnre  with  the  fin- 
gers of  one  hand,  the  contents  of  the  cyst  will  be  pressed  under  the 
fingers  of  the  other.  This  is  fluctuation  by  displacement,  not  by  the 
wave  produced  by  pressure. 


CYSTIC   TUMORS   OF   THE   OVARIES.  53-t 

The  fact  that  fluctuation  is  hmited  and  does  not  extend  throui:;h- 
ont  the  whole  abdominal  cavity  is  most  valuable  evidence  that  the 
fluid  is  encysted.  Further  evidence  of  this  is  also  obtained  by  an- 
other sign,  that  is,  the  tumor  does  not  change  its  form  when  the 
position  of  the  patient  is  changed.  By  turning  the  patient  flrst  on 
one  side  and  then  on  the  other,  it  will  be  observed  that  while  the 
tumor  may  gravitate  to  the  lower  side  it  does  not  change  its  form. 

In  the  second  stage  it  can  be  ascertained  that  the  tumor  is  at- 
tached to  the  broad  ligament.  This  sign  is  obtained  by  passing  the 
finger  of  one  hand  into  the  vagina  and  then  pushing  up  the  tumor 
with  the  other.  By  this  means  the  tumor  will  be  observed  to  drag 
upon  the  broad  ligament.  In  regard  to  the  signs  obtained  by  an 
examination  of  the  contents  of  the  cyst,  it  may  be  said  that  it  is  not 
often  that  this  need  be  resorted  to  in  the  second  stage,  but  when  it 
is,  the  reader  should  turn  to  the  description  of  the  contents  of  ovarian 
cysts  for  all  desired  information  on  this  point.  Tlie  physical  signs 
of  ovarian  and  other  abdominal  tumors  obtained  by  laparotomy  are, 
of  course,  peculiar  to  each.  The  descriptions  of  these  appearances 
may  help  one  to  recognize  such  tumors  when  seen  and  felt,  but  much 
experience  in  observation  is  necessary  to  tell  what  a  tumor  is  when 
one  sees  it  in  the  abdominal  cavity.  The  ambitious  and  rash  may 
open  the  abdomen  to  make  a  diagnosis,  and  be  unable  to  recognize 
that  which  they  find.  While  I  clearly  appreciate  the  value  of  lapa- 
rotomy as  a  means  of  diagnosis  in  obscure  cases,  I  am  as  fully  aware 
that  it  should  only  be  undertaken  by  one  possessing  comprehensive 
knowledge  gained  by  extensive  experience. 

There  are  certain  other  affections  and  conditions  which  resemble 
to  some  extent  ovarian  tumors  in  the  second  stage.  The  chief  of  these 
are  pregnancy,  normal  and  pathological,  neoplasms  of  the  uterus, 
such  as  fibroids  and  fibro-cysts  ;  distended  bladder  ;  fecal  impaction  ; 
encysted  fluid  in  the  peritoneal  cavity,  e.  g.,  in  tubercular  peritonitis  ; 
cysts  of  the  kidney,  liver,  or  spleen  ;  enlargement  and  displacement 
of  the  spleen,  kidney,  or  liver ;  cancerous  disease  of  any  of  the  ab- 
dominal organs,  omentum  or  abdominal  glands  ;  and  parovarian  cysts. 

Pregnancy,  in  its  normal  state,  differs  greatly  from  ovarian  tu- 
mors in  all  respects  but  the  fact  that  both  gravid  uterus  and  the 
tumor  occupy  the  abdominal  cavity,  still  a  number  of  cases  have  been 
reported  in  which  an  error  in  diagnosis  was  made,  and  ovariotomy 
undertaken  when  the  case  was  one  of  pregnancy.  In  several  of  these 
cases  the  trocar  has  been  thrust  into  the  uterus,  the  operator  believing 
that  he  was  tapping  an  ovarian  cyst.  At  the  present  time  such  a 
mistake  can  only  be  made  through  want  of  knowledge  or  lack  of 


5S2  DISEASES   OP   WOMEN. 

attention.  One  might,  in  trying  to  make  a  diagnosis,  mistake  the 
pregnant  uterus  for  an  ovarian  cyst,  but  upon  opening  the  abdomen 
one  having  knowledge  enough  to  warrant  him  in  undertaking  ovari- 
otomy ought  to  be  able  to  tell  the  one  from  the  other  by  sight. 

When  there  is  any  doul)t  it  is  far  better  to  wait  until  the  end  of 
tlie  time  of  gestation.  This  can  always  be  done.  There  is  no  good 
reason  for  removing  an  ovarian  cyst  until  it  is  as  large  as,  or  larger 
than,  the  uterus  at  full  term  of  gestation  in  doubtful  cases.  While 
1  believe  in  removing  ovarian  tumors  in  the  second  stage  of  their 
development  when  the  diagnosis  is  clear,  in  case  there  is  room  for 
doubt  whether  the  case  is  one  of  ovarian  cyst  or  of  pregnancy,  time 
will  decide,  and  there  is  no  valid  argument  against  waiting. 

The  fact  is  that  those  who  are  the  least  capable  of  making  a 
diagnosis  are  the  most  inclined  to  operate  early,  and  this,  I  presume, 
accounts  for  the  mistakes  recorded. 

I  need  not  give  the  differential  diagnosis  between  ovarian  tumors 
and  normal  pregnancy  ;  the  symptoms  and  signs  of  the  former  liave 
been  given,  and  those  of  the  latter  can  be  found  in  any  text-book  on 
obstetrics,  if  not  already  familiar  to  the  reader,  and  they  are  so  very 
different  that  by  contrast  the  diagnosis  can  be  made. 

Extra-Uterine  Pregnancy. — This  usually  comes  up  for  diagnosis 
in  connection  with  the  lirst  stage  in  the  growth  of  ovarian  tumors, 
as  has  already  been  stated.  It  is  only  the  abdominal  variety  which 
in  any  way  resembles  ovarian  tumors  in  the  second  stage.  The 
signs  of  a  living  child  in  the  abdomen  are  so  perfectly  diagnostic 
that  they  can  hardly  be  mistaken.  In  case  the  child  is  dead,  more 
difficulty  might  be  experienced  in  making  a  diagnosis.  The  history 
of  the  case  and  hallotteinent,  or  the  ability  to  move  the  dead  child  in 
the  sac,  will  usually  suffice  to  settle  the  question. 

Rupture  of  an  Ovarian  Cyst. — This,  and  the  extensive  adhesions 
which  follow,  most  closely  resemble  ventral  pregnancy  after  the 
death  of  the  child,  both  in  history  and  in  physical  signs,  and  I  can 
understand  that  it  miglit  be  impossible  to  discover  the  exact  nature 
of  the  trouble  without  the  aid  of  laparotomy.  Fortunately,  under 
these  circumstances  it  would  be  perfectly  right  to  employ  this 
method  of  making  the  diagnosis,  because  it  is  ])art  of  the  ajipropriate 
ti'eatment  in  either  case. 

In  the  cases  of  abdominal  ]>regnancy  that  I  have  seen  the  diag- 
nosis was  very  easy  ;  so  much  so  that  no  one  with  any  experience 
could  have  made  the  mistake  of  sus])ecting  ovarian  tumor. 

Uterine  Fibroids  and  Fibro-Cysts,  when  large,  present  some  of 
the  evidences  of  ovarian  tuniurs.     The  j)Osition  of  the  tumor  in  the 


CYSTIC  TUMORS   OF   THE   OVARIP^S.  533 

abdomen,  and  its  shape  and  mobility,  are  tlie  same  as  those  of  some 
ovarian  tumors,  and  these  are  the  only  resemblances. 

In  iibroids,  the  uterus  is  enlarged  as  shown  by  the  touch  and 
sound.  The  tumor  is  solid  and  is  intimately  connected  with  the 
uterus,  in  fact  forms  a  part  of  it.  In  the  majority  of  cases  the  cav- 
ity of  the  uterus  can  be  probed,  and  will  be  found  enlarged  in  case 
the  tumor  is  uterine,  while  it  will  not  be  if  the  tumor  is  ovarian. 

Distended  Bladder  has  been  mistaken  for  a  cyst  of  the  ovary, 
but  only  at  a  tirst  examination  or  by  one  not  used  to  such  cases. 
When  the  bladder  is  overdistended  there  is  incontinence,  usually 
the  urine  coming  away  constantly,  or  in  spurts  when  the  patient 
moves.  This  leads  the  medical  attendant  to  suppose  that  the  blad- 
der must  be  empty  and  that  the  tumor  is  an  ovarian  cyst,  but  the 
catheter  readily  settles  the  question,  and  it  should  always  be  used  in 
cases  with  such  histories. 

Fecal  Impaction  has  always  been  mentioned  as  one  of  the  condi- 
tions which  might  be  mistaken  for  an  ovarian  tumor,  but  I  have  not 
considered  such  a  thing  possible.  The  irregular  form  and  solid 
character  of  the  fecal  mass  differs  in  every  respect  from  ovarian 
tumors  of  all  the  benign  variety. 

Encysted  Dropsy  of  the  Peritonaeum. — This  is  an  extremely  rare 
affection  and  occurs  in  the  progress  of  tubercular  disease  as  a  rule, 
and  follows  an  attack  of  peritonitis.  The  physical  signs  differ,  in 
that  the  fluctuation  is  not  so  general  as  in  ovarian  cyst,  and  the  fixa- 
tion is  complete.  The  surface  of  the  abdomen  is  not  so  prominent 
as  in  case  of  a  cyst,  but  often  has  irregular  depressions,  as  well  as 
elevations,  and  the  veins  are  not  prominent. 

The  general  health  is  greatly  reduced  early  in  the  progress  of 
the  disease  ;  nutrition  is  markedly  impaired,  and  there  is  often  sep- 
ticsemia  in  case  that  there  is  pus  encysted. 

The  vaginal  examination  is  often  quite  sufficient  to  settle  the 
diagnosis,  by  showing  that  the  pelvic  organs  are  normal  and  can  be 
outlined  and  separated  from  the  mass  in  the  abdomen.  When  this 
can  be  accomplished,  ovarian  disease  is  at  once  excluded. 

Enlargement  and  Cysts  of  the  Liver,  Spleen,  and  Kidneys. — In  all 
of  these  the  diagnosis,  so  far  as  the  exclusion  of  ovarian  disease,  can 
be  easily  made  if  the  cases  are  seen  early,  or  a  correct  history  can  be 
obtained.  It  is  found  that  in  them  all  the  enlargement  begins 
above  and  on  one  side,  and,  as  a  rule,  is  fixed  there  from  the  begin- 
ning, and  the  pelvic  organs  can  be  separated  from  the  tumor  above, 
and  proved  to  have  no  connection  with  the  morbid  growth,  and  to 
be  normal.     These  two  diagnostic  facts  will  suffice  in  most  cases  to 


534  DISEASES   OF   WOMEN. 

settle  the  question,  but  additional  evidence  can  be  obtained  from  the 
general  liistory  of  the  growth  and  its  effects  upon  the  general 
health,  also  the  composition  of  the  fluid  in  cysts,  wliich  should  be 
obtained  by  aspiration  in  doubtful  cases. 

In  regard  to  the  differential  diagnosis  in  cancer  of  the  pelvic  and 
abdominal  organs,  this  will  be  discussed  in  connection  with  these 
affections,  and  hence  is  omitted  here. 

Parovarian  Cysts,  or  serous  cysts  of  the  broad  ligament,  as  they  are 
called,  are  not  very  easily  recognized  at  all  times.  Fortunately  it 
would  be  no  very  great  mistake  to  remove  one  of  these  cysts  suppos- 
ing that  it  was  an  ovarian  cyst.  They  are  very  rare  as  comjjared 
with  ovarian  cysts,  they  grow  slowly,  and  occur  mostly  in  young  per- 
sons. The  general  health  does  not  suffer,  as  a  rule.  The  physical  signs 
differ  in  no  way  from  those  of  the  ovarian  monocyst,  except  that 
the  fluctuation  is  more  distinct  and  the  fluid  differs,  being  clear  like 
water  and  without  albumen.  Tapping,  or  rather  exploratory  aspira- 
tion, is  the  means  to  be  employed  to  settle  the  diagnosis,  and  should 
be  practiced  when  there  is  a  doubt. 

Affections  which  resemble  Ovarian  Neoplasms  in  the  Third  Stage. 
— There  are  only  a  few  affV'ctions  wdiich  resemble  ovarian  cysts  in 
the  third  stage.  These  are  ascites,  uterine  flbro-cysts,  and  very  large 
uterine  libromata. 

The  flrst  mentioned,  ascites,  is  the  most  likely  to  be  mistaken  for 
ovarian  cyst.  The  chief  points  of  difference  in  history  are,  that  as- 
cites is,  as  a  rule,  preceded  by  some  acute  disease  or  general  ill- 
health,  suggestive  of  some  chronic  disease  of  the  liver,  heart,  or  kid- 
neys. There  is  anasarca  also  in  most  cases  of  ascites,  and  the  pa- 
tient is  generally  anaemic  early  in  the  progress  of  the  disease.  The 
enlargement  of  the  abdomen  comes  on  i-ather  suddenly,  and  is  not 
conflned  to  its  lower  part;  that  is,  it  is  not  circumscribed.  The  ex- 
pression of  the  face,  while  showing  ana^nia  in  ascites,  is  not  anxious, 
as  it  usually  is  in  ovarian  cyst.  The  history  of  ovarian  cyst  in 
growth  and  genei-al  constitutional  symjotoms  is  almost  the  reverse  of 
ascites. 

The  physical  signs  of  ascites  differ  from  ovarian  cyst,  chiefly  in 
that  the  fluid  in  ascites  changes  its  position  with  every  change  in  the 
position  of  the  patient.  When  the  patient  is  placed  upon  the  back, 
the  abdomen  is  symmetrical  and  flat ;  in  the  erect  position,  the  lower 
portion  bulges  from  the  gravitation  of  the  fluid,  and  the  same 
change  in  the  position  of  the  fluid  occurs  when  the  patient  is  turned 
toward  either  side.  With  these  changes  in  the  position  of  the  fluid, 
there  is  a  change  in  the  resonance  on  percussion.     The  flatness  is 


CYSTIC   TUMORS   OF   THE   OVARIES.  535 

found  at  the  most  dependent  part,  while  the  resonance  is  found  at 
the  upper. 

In  large  cysts  there  is  dullness  or  flatness  on  percussion  at  all 
points  except  tlie  flanks,  where  there  is  always  resonance,  except 
when  the  colon  is  distended  with  gas  and  flxed  deep  in  the  side,  so 
that  the  fluid  of  ascites  can  not  gravitate  below  it ;  and  in  ovarian 
cyst  there  may  be  dullness  on  percussion  in  the  side  due  to  fecal  im- 
paction of  the  colon. 

There  is  another  exception  to  the  rule  that  in  ascites  there  is 
always  resonance  at  the  highest  point  of  the  abdomen  whatever  the 
position  of  the  patient  may  be,  and  that  is  when  the  disturbance 
of  the  abdomen  is  extreme,  and  the  mesentery  is  not  long  enough 
to  permit  the  intestines  to  rise  to  the  top  of  the  fluid  while  the  pa- 
tient is  upon  the  back.  There  is  also  a  diiference  in  the  fluids,  which 
gives  some  help  in  the  diagnosis  in  case  aspiration  is  practicable,  as 
it  may  be  in  doubtful  cases. 

Uterine  Fibro-Cysts  or  Fibromata  seldom  attain  suflficient  size  to 
resemble  ovarian  cysts,  but  occasionally  they  do  so.  The  fibro-cysts 
of  the  uterus  more  closely  simulate  the  ovarian  cystic  tumors  than 
the  fibromata.  The  difference  in  the  history  and  the  fact  that  the 
uterus  is  involved  in  the  tumor  in  fibro-cyst  and  free  in  the  other 
form,  are  the  chief  points  of  difference.  This  subject  was  discussed 
in  treating  of  the  diagnosis  in  the  second  stage  of  ovarian  tumors, 
and  need  not  be  repeated  in  full  in  this  connection. 

Intraligamentous  Ovarian  Cystomata. — I  deem  this  variety  of 
ovarian  tumor  of  sutficient  importance  to  merit  a  separate  consid- 
eration. 

The  difference  between  intraligamentous  and  the  ordinary  forms 
of  ovarian  cystomata  is  simply  in  the  position  they  occupy  in  rela- 
tion to  the  ligaments.  The  location  may  be  called  an  unnatural  one, 
Ijecause  it  differs  from  that  which  ovarian  cystomata  usually  occupy. 

The  intraligamentous  ovarian  cystomata  are  comparatively  quite 
rare.  This  suggests  that  the  causes  opei'ative  in  determining  their 
location  are  exceptional.  Two  theories  have  been  advanced  to  ex- 
plain the  topographical  anatomy  of  intraligamentous  cystomata.  The 
one  assumes  that,  owing  to  some  error  of  development,  the  ovary, 
during  embryonic  life,  finds  its  way  into  the  folds  of  the  broad 
ligament  and  there  remains.  In  that  case,  if  a  cystoma  of  the  abnor- 
mally located  ovary  occurs  it  is  certain  to  split  up  the  ligament  and 
convert  it  into  a  capsule  for  itself. 

The  second  theory  is,  that  during  the  growth  of  the  cystoma  it 
burrows,  so  to  speak,  into  tlie  folds  of  the  ligament,  and  once  having 


536  DISEASES   OF    WOMEN. 

insinuated  itself  there  pushes  the  folds  apart,  and  these  folds  grow 
with  the  cystoma  and  form  a  ligamentous  capsule  for  it.  In  order 
that  this  may  come  about,  the  ovary  must  be  closely  attached  to  tlie 
ligament,  in  place  of  being  held  by  a  special  fold  of  ])eritona^um, 
which  leaves  it  to  some  extent  free  from  the  ligament  proper.  Or 
the  ovary  may  be  bound  down  to  the  ligament  by  an  inHammatory 
adhesion.  Where  a  cyst  develops  deep  in  the  ovary  and  meets  re- 
sistance on  the  free  peritoneal  surface,  it  pushes  its  way  in  between 
the  folds  of  the  ligament.  There  is  good  evidence  in  favor  of  this 
theory  in  the  fact  that  these  cystomata  come  from  the  paroophoron, 
which  is  the  portion  of  the  ovary  that  is  nearest  to  the  uterine 
ligament.  Furtherniore,  I  have  in  one  of  my  own  cases  found  the 
ovary  from  which  the  cystomata  came  imbedded  in  the  postei'ior 
fold  of  the  ligament.  It  would  be  more  correct,  perhaps,  to  say  that 
the  ovary  was  stretched  out  uj^on  the  posterior  fold  of  the  ligament. 
It  was  so  changed  in  form  that  I  should  have  overlooked  it  had  it 
not  been  that  there  were  several  small  cysts  in  it  surrounded  by 
what  appeared  to  be  ovarian  stroma. 

In  another  case  I  found,  while  enucleating  the  cyst,  that  it  was 
very  firmly  adherent  at  a  point  in  the  posterior  fold  of  the  liga- 
ment where  the  ovary  should  be  found.  The  vessels  Avere  lai-ger  at 
that  point  than  anywhere  else,  which  led  me  to  think  that  the  ovary 
was  there;  l)ut  the  tissues  were  so  changed  l)y  inliannnatory  products 
that  I  could  not  positively  detect  any  ovarian  tissue.  This,  I  think. 
is  sufficient  to  settle  this  point  in  the  })athology  and  causation  of  some 
of  these  cystomata,  and  presumably  the  larger  portion,  if  not  all.  of 
them.  Still,  it  may  be  admitted  that  malposition  of  the  ovary,  be- 
cause of  a  lesion  of  development,  may  obtain  in  some  cases. 

PafhoJfxj!/. — These  cystomata  may  be  single  or  multiple.  I 
think,  however,  they  are  more  often  single.  All  of  my  own  cases, 
eight  in  number,  have  been  nionocysts.  Another  interesting  feature 
is  that  they  are  generally  papillary  or  proliferous  cysts.  This,  ac- 
cording to  some  anthorities,  notal)ly  Bland  Sutton,  of  London,  is  due 
to  the  fact  that  they  are  developed  from  the  deeper  structures  of  the 
ovary,  the  paro(')|)li(iron,  as  already  noted. 

The  position  of  these  cystomata  and  their  relations  to  the  pelvic 
organs  have  a  very  imj)oi-tant  bearing  upon  the  question  of  treat- 
ment, as  will  be  seen  fiii-thcr  on. 

In  my  own  practice.  I  have  found  them  occupying  widely  difier- 
ing  positions  in  relation  to  the  ligaments  and  pelvic  organs.  In 
some,  the  tumor  was  situated  in  one  ligament,  displacing  the  uterus 
to  the  opposite  side  of  the  j)elvis,  and,  in  a  lesser  degree,  the  bladder 


CYSTIC   TUMORS   OF   THE   OVARIES.  537 

also.  In  others,  the  tumor  occupied  a  position  in  both,  ligaments  and 
between  the  uterus  and  bladder.  When  thus  located  the  tumor, 
uterus,  bladder,  and  ligaments  have  been  found  high  up  out  of  the 
pelvis,  so  that  the  most  dependent  portion  of  the  tumor  could  not 
be  easily  reached  through  the  vagina.  Again,  I  have  found  the 
tumor  behind  both  the  uterus  and  bladder,  and  yet  between  the 
folds  of  both  ligaments.  In  all  these  the  pelvic  organs  were 
carried  up  into  the  abdominal  cavity,  while  the  tumor  descended 
deeply  into  the  pelvis.  It  appears  that  there  is  a  rule  which  deter- 
mines the  location  of  those  tumors  which  occupy  both  ligaments,  in 
regard  to  their  relations  to  the  pelvic  and  abdominal  cavities.  This 
rule  may  be  formulated  as  follows :  When  the  tumor  is  between  the 
uterus  and  bladder,  all  three  structures  rise  up  into  the  abdomen; 
whereas,  if  both  of  these  organs  are  in  front  of  the  tumor,  it  dips 
well  down  into  the  pelvis.  The  reason  is,  that  in  the  one  case  the 
vagina  arrests  thfe  process  of  burrowing  downward,  while  in  the 
other  there  is  no  resistance  to  the  descent  of  the  cystoma. 

In  all  cases  the  broad  ligaments  become  greatly  enlarged  and 
thickened,  usually  covering  the  whole  cyst,  although  they  are  thinned 
out  at  the  upper  portion.  When  the  cyst  does  not  descend  into  the 
pelvis  and  has  attained  considerable  size,  the  upper  portion  of  the 
cyst  may  present  a  wall  of  medium  thickness ;  in  fact,  the  liga 
raents  diminish  in  thickness  and  vascularity  until  there  is  little  left 
but  the  peritonaeum ;  and  the  upper  part  of  the  cyst  then  appears 
more  like  an  ordinary  intraperitoneal  ovarian  cystoma. 

These  facts  are  of  the  utmost  importance  in  regard  to  treatment, 
and  hence  the  reason  for  this  brief  account  of  the  various  positions 
in  which  these  intraligamentous  cystomata  may  occur. 

Symptomatology . — These  tumors  cause  more  pain  and  functional 
derangement  of  the  pelvic  organs  than  the  ordinary  ovarian  cysto- 
mata, but  in  other  respects  the  history  is  the  same. 

Physical  Signs. — The  diagnosis  of  such  cases  is  of  interest  chiefly 
because  of  the  difficulties  encountered  in  operating  and  the  urgent 
necessity  of  clearly  comprehending  the  exact  conditions  present,  in 
order  to  manage  them  to  the  best  advantage.  I  have  found  it  im- 
possible to  make  a  complete  and  comprehensive  diagnosis  in  all 
cases.  It  is  generally  possible  to  make  out  that  there  was  a  cystoma 
in  the  broad  ligament,  but  with  no  definite  certainty  as  to  its  posi- 
tion and  topographical  anatomy.  Judging  from  the  literature  of 
the  subject,  it  appears  that  others  have  suffered  from  a  like  uncer- 
tainty in  some  cases.  When  a  cystic  tumor  exists  in  the  abdomen 
and  is  firmly  fixed  below,  with  no  history  of  infiannnation  during  the 


538  DISEASES  OF   WOMEN. 

earlier  stages  of  the  growth  of  the  tumor,  and  the  uterus  is  drawn 
u])  out  of  the  pelvis  and  lies  behind  or  in  front  of  the  cystoma,  I 
suspect  tliat  it  is  intraligamentous.  If  the  uterus  is  displaced  later- 
ally in  a  marked  degree  by  the  cj'stoma  that  is  present,  or  if  the 
cyst  descends  deep  down  into  the  pelvis  while  the  nterus  is  high  up 
and  in  front  of  the  cyst,  the  facts  point  to  the  same  conclusion. 
When  a  portion  of  the  tumor  found  in  the  pelvis  is  cystic,  this  is  a 
great  aid  ;  but.  as  a  rule,  these  tumors,  as  already  stated,  are  prolifer- 
ous, and  there  is  so  much  solid  material  in  the  most  dependent  part 
that  fluctuation  is  not  found,  and  the  tumor  appears  to  be  soHd  to  the 
touch  and  may  l.)e  mistaken  for  a  libroma  or  fibrocyst  of  the  uterus. 
One  case  was  seen  by  two  well-known  ovariotomists,  and  both  sus- 
pected fibroma  of  the  uterus  as  well  as  ovarian  cystoma.  My  first 
impressions  were  the  same,  but  ujion  opening  the  abdomen  I  found 
the  uterus  normal,  but  displaced  upward  by  an  intraligamentous 
ovarian  cystoma.  * 

Cases  may  be  divided  into  two  classes — those  in  which  a  com- 
plete diagnosis  can  be  made,  and  those  in  which  the  diagnosis  is 
incomplete.  In  the  one,  the  nature  and  composition  of  the  tumor, 
its  relations  to  the  abdominal  and  pelvic  organs,  and  the  extent  and 
location  of  its  attachments,  can  be  clearly  determined;  in  the  other, 
which  is  incom])lete,  there  may  l)e  suthcient  evidence  to  Avarrant 
either  operative  treatment  or  a  full  assurance  that  the  case  is  not 
amenal)le  to  surgical  treatment.  The  lirst  or  complete  diagnosis  can 
1)6  made  from  the  usual  physical  signs  and  the  history.  The  incom- 
plete diagnosis  may  be  made  complete  by  surgical  means,  such  as 
aspirating  or  by  laparatomy.  It  is  of  tlie  utmost  importance  to  dif- 
ferentiate between  these  two  classes  of  cases.  When  only  a  partial 
diagnosis  can  be  made,  leaving  doubts  as  to  a  possible  malignant  ele- 
ment existing  in  the  case,  the  cpiestion  of  the  pro])riety  of  ovariotomy 
may  be  determined  by  an  examination  of  the  intraperitoneal  Huid, 
which  is  often  present.  If  this  ]u-oves  negative,  the  operation  is 
advisable;  while,  if  the  cells  characteristic  of  malignant  disease  are 
found,  the  case  should  be  left  alone.  Keeping  still  to  the  (piestion 
of  diagnosis,  I  may  say  that  in  cases  of  intraligamentous  cystomata 
one  can  usually  make  sure  that  an  operation  is  called  for  and  is  jus- 
tifiable, but  the  diagn(»sis  must  often  remain  incom])lete  until  the 
abdomen  is  o])en('(l.  At  the  same  time  it  is  not  an  easy  task  to  com- 
plete the  diagnosis  aftci-  lapai-otomy.  A  few  words  on  this  subject 
may  be  admissibU\  in  view  of  the  inqiortance  of  the  matter.  We 
hear  much  of  making  an  exploratory  operation  for  diagnostic  pur- 
poses, but  I  am  satisfied  that  skill  and  exiH'rience  are  very  necessary 


CYSTIC   TUMORS   OF   THE   OVARIES.  539 

to  do  this.  To  recoii:;nize  just  what  is  present,  and  to  determine  what 
to  do  in  these  cases  wlien  the  tumor  is  exposed,  is  no  easy  task  ;  and 
still,  upon  a  rapid  inspection  and  palpation,  and  prompt  decision 
regarding  the  exact  conditions  and  how  to  manage  them,  depends 
the  success  of  the  surgeon  in  complicated  cases.  I  may  not  have 
seen  or  carefully  thought  of  all  the  conditions  which  simulate,  and 
hence  may  he  mistaken  for,  intraligamentous  cystomata,  l)ut  such 
«)l)servations  as  I  have  made  cover  the  most  important  part  of  the 
ground. 

When  the  tumor  is  exposed  hy  laj)arotomy  its  intraligamentous 
character  can  he  determined  by  incising  the  peritomTeum,  which  will 
retract  and  expose  the  cyst-wall.  In  all  other  tuniors  the  perito- 
Uieum  is  so  closely  adherent  that  no  retraction  occurs.  The  appear- 
ance resembles  most  closely  a  uterine  fibroma,  and  owing  to  the 
thickness  of  its  walls  it  feels  to  the  touch  like  a  fibroma,  especially 
if  the  cyst  has  very  tense  walls,  as  usually  is  the  case ;  but  by  rest- 
ing one  finger  on  the  tumor  and  ])ercussing  the  abdominal  wall 
at  a  distant  point,  fluctuation  can  be  unmistakably  made  out.  This 
excludes  fibroma  at  once,  but  still  leaves  the  possibility  of  the  tumor 
l)eing  a  uterine  fibrocyst,  and,  although  this  is  not  important  as  bear- 
ing upon  the  main  question  of  removal  of  the  tumor,  it  affects  the 
method  of  procedure  and  should  be  correctly  decided  at  once.  This 
can  be  done  by  tapping,  which  shows  the  character  of  the  fluid, 
which  is  all-sufiicient,  with  few  exceptions.  If  pus  is  found,  it  may 
Ije  impossible  to  say  whether  the  cyst  is  uterine  or  ovarian.  The 
tapping,  however,  gives  more  room  for  the  introduction  of  the  hand, 
which  enables  the  operator  to  make  out  the  attachments  and  the 
relation  of  the  tumor  to  the  pelvic  organs,  and  thereby  complete  the 
differentiation. 

The  pregnant  uterus  also  looks,  in  color  and  vascularity,  like  this 
form  of  tumor,  and  may  lead  to  doubt.  At  least  I  think  that  when 
this  mistake  has  been  made,  an  intraligamentous  tumor  must  have 
Ijeen  suspected,  because  it  is  the  only  ovarian  cystoma  that  appears 
at  all  like  the  uterus.  This  can  be  made  clear  by  observing  con- 
tractions of  the  uterus,  which  can  be  easily  excited,  and  by  passing 
the  hand  into  the  abdomen  the  ovaries  can  be  found,  and  the  condi- 
tion of  the  cervix  uteri  and  normal  ligaments  will  show  that  there 
is  pregnancy. 

Treatment. — These  tumors  require  special  treatment,  owing  to 
the  fact  that  they  are  not  pedunculated  like  the  ordinary  cystomata, 
but  are  encapsulated,  and  differ  in  their  relations  to  the  pelvic 
<jrsans. 


5J:0  DISEASES   OF   WOMEN. 

The  several  inetliuds  adopted  in  operating  are  as  follows :  Enu- 
cleation ranks  first,  becanse  it  is  adapted  to  more  cases,  perhaps,  than 
any  other.  This  well-known  method,  devised  and  introduced  by 
Dr.  Miner,  of  Buffalo,  has  been  practiced  bv  many  ovariotomists. 
It  was  employed  in  the  treatment  of  ordinary  pedunculated  cystoma 
M'hen  first  brought  out,  and  is  now  seldom  practiced  excejit  in  par- 
ovarian cysts.  In  fact,  I  do  not  think  that  Dr.  Miner  ever  employed 
his  method  in  the  treatment  of  the  class  of  cases  now  under  con- 
sideration ;  but  if  he  did,  he  omitted  a  description  of  some  of  the 
details  which  are  necessary.  Enucleation  is  adapted  to  all  cases  in 
which  the  cystoma  descends  into  the  pelvis,  completely  separating 
one  or  both  ligaments.  In  all  such  cases  it  should  be  tried,  and  it 
will  succeed  well  unless  there  has  been  infiannnatory  action  which 
has  firndy  united  the  cyst-wall  and  folds  of  the  ligaments,  or  the 
cyst-wall  is  thin  and  friable. 

In  such  conditions  the  enucleation  may  prove  to  be  impossil)le, 
and  other  means  of  treatment,  to  be  hereafter  noted,  must  be  adopt- 
ed. In  the  first  jilace,  it  is  important  to  tap  the  cyst  high  up,  in 
order  to  avoid  wounding  the  thickest  portion  of  the  broad  ligament. 
To  do  this  it  is  sometimes  necessary  to  extend  the  incision  in  the 
wall  of  the  al)domen  higher  than  usual.  The  cyst  being  emptied 
and  drawn  well  out  of  the  wound,  the  separation  of  the  ligament 
and  cyst-wall  sliould  be  begun  at  that  point  high  up  where  the  liga- 
ment is  so  thinned  out  as  to  be  hardly  noticeable.  AVhen  the  dis- 
section is  begun  all  around,  the  capsule  can  be  lifted  up  and  the 
dissection  continued  with  the  knife-handle,  and  finally  the  deeper 
portions  can  be  separated  with  the  finger.  Tlie  traction  should  l)e 
made  upon  the  cyst-wall,  as  the  capsule  or  ligaments  is  easily  lacer- 
ated. During  enucleation,  if  any  large  vessel,  artery,  or  vein  is  in- 
jui-ed,  it  sbould  l)e  ligated  or  controlled  with  forceps  at  once.  The 
management  of  the  ligaments,  after  the  cystoma  is  removed,  is  first 
directed  to  tlie  control  of  liaMnoi-rhage.  In  some  cases  a  general 
oozing  is  all  that  thei-e  is.  Occasionally  a  wounded  vessel  here  and 
there  needs  ligating.  AVhen  the  cyst  extends  dee[)  down  into  the 
jX'lvis,  there  is  often  vei-y  tr()ul)lesome  ])leeding  from  veins.  These 
should  be  ligated,  if  })ossil)le;  but  if  that  can  not  l)e  done,  pressure 
with  a  hot  sponge  should  be  tried,  and,  if  that  fail,  styi)tics  may  be 
used.  The  ligamentous  cajisule  now  presents  a  ])ouch,  the  inner 
surface  of  which  is  raw,  and  from  which  there  will  be  some  bleed- 
in<;  and  nnich  serous  oozinoj.  This  sliould  be  treated  as  follows: 
The  upper  portion  of  the  o|)posing  sides  should  he  folded  in  so  as 
to  bring  the  peritoneal  surfaces  together,  and  these  should  ])e  fixed 


CYSTIC   TUMORS   OP   THE   OVARIES.  541 

by  a  continuous  catgut  suture.  The  suturing  should  begin  on 
both  sides,  and  be  from  the  sides  toward  the  center,  and  ckjse  the 
parts,  except  at  a  })oint  beneath  the  abdominal  wound,  where  an 
open  space  should  be  left  for  the  drainage-tube.  If  the  ligaments 
thus  approximated  by  sutures  can  be  brought  up  to  the  lower 
angle  of  the  abdominal  wound,  they  should  be  fixed  to  the  abdomi- 
nal wall  by  silk  sutures  passed  through  the  ligaments  on  each  side 
of  the  opening  for  the  drainage-tube,  and  then  through  the  wall  of 
tiie  al)domen.  When  the  ligaments  can  not  be  brought  up  to  the 
wall  of  the  abdomen,  a  drainage-tube  without  side-openings,  should 
be  carried  down  to  the  bottom  of  the  cavity. 

While  this  mode  of  treatment  is  perfectly  satisfactory  in  suitable 
cases,  there  are  difficulties  attending  the  operation  in  exceptional 
cases,  and  hence  certain  dangers  The  cyst- wall  may  be  easily  torn, 
and  there  is  liability  of  leaving  portions  of  it.  When  this  happens, 
it  is  necessary  to  destroy  the  secreting  surface.  This  may  possibly 
be  done  by  ajjplying  pure  carbolic  acid.  The  most  difiicult  part  of 
the  operation  is,  in  some  cases,  to  stop  the  bleeding.  This  has  been 
referred  to ;  but  I  may  say  further,  that  the  oozing  at  the  time  of 
operating,  and  the  liability  to  suppuration  which  may  occur  after- 
ward, render  the  convalescence  rather  tedious  in  many  cases. 

The  next  procedure  is  to  remove  the  cystoma,  and  its  capsule 
also,  by  ligating  the  ligament  below  the  tumor.  This  method  is 
adapted  to  those  cases  in  which  the  cyst  is  situated  in  one  broad  liga- 
ment and  does  not  dip  down  very  far  into  the  pelvis.  Such  cases 
are  described  in  books  as  having  a  very  broad  pedicle,  l)ut  the  most 
that  can  be  correctly  said  of  them  is  that  they  are  ])artially  pedun- 
culated. In  this  condition  the  ligament  can  be  ligated  with  the 
repeated  continuous  ligature.  This  is  applied  in  the  following  man- 
ner :  One  end  of  the  ligature  is  passed  through  tlie  ligament  and  a 
portion  of  it  tied,  then  the  other  end  of  it  is  jjassed  through  the 
portion  wdiich  is  already  ligated,  carried  forward,  and  l)rought  l)ack 
through  the  ligament  in  such  a  way  as  to  secure  another  jiortion, 
aiid  the  two  ends  again  tied,  and  so  on  until  the  Avliole  is  secured. 
The  cyst  and  its  capsule  are  then  cut  oft".  This  leaves  no  cavity, 
arrests  all  possil)le  haemorrhage,  and  in  this  respect  is  all  that  can  l)e 
desired.  But  there  are  difficulties  and  dangers  that  may  arise,  even 
in  cases  where  the  method  is  applicable.  There  is  danger  of  wounding 
the  ureter  or  including  it  in  the  ligature.  A  knowledge  of  the  loca- 
tion of  the  ureter  and  its  anatomical  relations  is  not  always  sufficient 
to  guard  against  this  accident,  because  the  ureter  may  be  displaced. 
By  drawing  the  cyst  and  ligament  out  of  the  abdominal  wound,  it 


542  DISEASES   OF  WOMEN. 

may  be  possible  to  see  that  tlje  ureter  is  not  in  the  way ;  bnt  this 
can  not  always  be  done,  and  then  one  has  to  depend  upon  the  touch 
to  localize  the  ureter  and  avoid  it.  This  is  possible,  owing  to  the 
fact  that  the  ureter  feels  like  a  cord  crossing  the  ligament ;  but  in 
case  the  tissues  are  thickened  by  inllannnatory  products  it  is  difficult 
indeed  to  find  the  ureter. 

There  is  still  another  way  of  managing  these  cases,  and  that  is 
by  a  combination  of  the  two  methods  already  described.  It  is  well 
adapted  to  cases  that  can  be  enucleated  easily,  and  has  the  advantage 
of  surely  avoiding  the  ureter.  The  cyst  is  first  enucleated,  and  the 
capsule,  or  so-called  pedicle,  is  tied  and  cut  off.  The  advantages 
are.  that  it  is  easier  to  handle  the  capsule  after  the  cyst  is  removed, 
and  there  is  no  danger  of  including  any  portion  of  the  cyst  in  the 
ligature — an  accident  that  may  occur  in  operating  by  the  second 
inethod  alone.  There  is  one  fortunate  feature  in  this  method  of 
treatment,  viz.,  in  case  enucleation  can  not  be  effected,  ligation  alone 
can  be  resorted  to.  It  is  well,  then,  to  try  enucleation,  even  if  it  has 
to  be  abandoned. 

There  still  remain  for  consideration  tumors  that  can  not  be  re- 
moved by  any  of  the  methods  known  at  the  present  time,  and  there 
are  such.  A  cystoma  that  descends  into  the  pelvis  and  has  become 
firmly  adherent  to  the  ligaments  by  inflammatory  products,  can  not 
be  enucleated,  neither  can  the  capsule  be  ligated.  At  least  enucle- 
ation can  not  be  done  with  any  degree  of  safety.  That  complete 
removal  of  such  tumors  has  been  tried,  is  no  doubt  true,  but  the 
result  has  been  to  open  into  the  rectum,  and  cause  uncontrollable 
bleeding  or  peritonitis,  either  of  which  must  prove  fatal.  These 
complications  are  always  present  in  suppurating  intraligamentous 
cystomata,  and  hence  when  pus  is  found  on  tapjiing,  it  may  l)e  in- 
ferred that  enucleation  is  impossible.  I  have  found,  however,  that 
a  non-snppurative  cellulitis  lias  so  firmly  united  the  cyst-wall  to  the 
ligamentous  capsule  that  they  could  not  be  separated.  The  treat- 
ment of  such  cases  is  by  drainage.  I  am  Avell  aware  that  the  more 
skillful  the  operator,  the  more  surely  will  he  overcome  difficulties, 
and  the  more  frecpiently  will  he  have  comi)lete  oi)erations  ;  but  when 
the  conditions  wliich  have  been  named  are  pivsent,  I  am  confident 
that  it  is  wiser  and  better  to  empty  the  cystoma  and  unite  the  cyst- 
wall  to  the  abdominal  wall,  and  then  drain  by  means  of  the  ordinai-y 
tul)e.  The  cyst  fiuid  is  usually  septic  (this  is  always  so  in  suppu- 
rating cysts),  and  it  is  very  difficult  indeed  to  sa\e  the  peritonaeum 
and  alxlominal  wounds  from  contamination.  After  emptying  the 
cyst  and  opening  it,  it  should  be  thoroughly  cleaned  out  with  sjionges 


CYSTIC   TUMORS   OF   THE   OVARIES.  543 

or  absorbent  cotton,  and  papillary  tissue,  if  present,  may  be  scraped 
oft".  This  slionld  be  done  with  the  cyst  drawn  well  out  of  the  wound. 
If  the  cystoma  is  large,  an  effort  should  be  made  to  separate  the  cyst- 
wall  from  the  ca])su]e  as  far  down  as  possible.  If  that  can  be  done, 
the  detached  portion  of  the  sac  is  then  cut  off,  leaving  it  of  suffi- 
cient length  so  that  the  central  portion  will  come  up  to  the  abdominal 
wall  without  dragging.  Bleeding  vessels  in  the  cyst-wall  are  ligated 
or  twisted.  The  detached  portions  of  the  capsule  are  folded  into 
the  cyst  and  united  with  a  continuous  suture,  beginning  on  each  side 
and  continuing  toward  the  center,  but  leaving  space  enough  between 
their  meeting  to  admit  tlie  drainage-tube.  In  this,  great  care  has  to 
be  taken  to  keep  the  hands  and  instruments,  which  have  touched 
the  inside  of  the  cyst,  from  coming  in  contact  with  the  peritonseum 
or  abdominal  wound.  Again,  in  fastening  the  partially  closed  cyst 
to  the  abdominal  wall,  it  is  necessary  to  pass  the  needle  from  the 
abdominal  wall  into  the  cyst,  and  not  use  that  needle  again  unless  it 
is  thoroughly  cleansed.  If,  on  the  contrary,  the  sutures  are  passed 
from  the  inside  of  the  cyst  outward,  septic  material  will  surely  be 
carried  into  the  tissues  of  the  abdominal  wall,  and  trouble  will  fol- 
low. One  suture  on  each  side  of  the  opening  in  the  cyst  for  the 
drainage-tube  will  suffice  to  unite  the  wall  of  the  cyst  and  the  ab- 
dominal wall  at  these  points ;  and  one  suture  above,  and  one  below, 
carried  through  the  sides  of  the  abdominal  wall,  and  into  the  cj^t- 
wall,  but  not  through,  will  complete  the  coaptation.  If  this  much 
is  accomplished  without  contaminating  the  normal  tissues,  there  is 
very  little  danger  of  septic  peritonitis  occurring,  or  septic  inflamma- 
tion of  the  abdominal  walls.  The  drainage  is  so  perfect  that,  though 
suppuration  in  the  remaining  portion  of  the  cyst  may  go  on,  there 
is  not  much  danger  from  it  if  it  does  not  extend  outside  the  sac. 
The  drainage  must  be  long  continued,  and  the  convalescence  is  very 
slow,  compa]-atively.  In  case  the  secreting  surface  of  the  cyst  has 
been  thoroughly  destroyed  by  suppuration,  the  recovery  is  usually 
not  long  delayed.  Contraction  and  closure  of  the  cavity  come  in  a 
month  or  therealjout.  If,  on  the  otlier  hand,  the  secreting  surface 
is  left,  the  discharge  may  go  on  for  months ;  but  the  patient,  mean- 
time, may  completely  regain  her  health  and  be  able  to  attend  to  her 
duties  comfortably.  When  a  small  pocket  and  sinus  remain,  it 
facilitates  recovery  to  inject  iodine  or  carbolic  acid.  I  may  be  preju- 
diced in  favor  of  this  mode  of  treating  such  cases  from  the  fact  that 
I  have  had  two  intraligamentous  cystomata  and  four  adherent  ordi- 
nary ovarian  cystomata  which  were  treated  by  drainage,  and  all 
recovered. 


CHAPTER   XXIX. 

OVARIOTOIVIY. 

The  operation  of  removing  ovarian  tmnors  has  been  generally 
known  as  ovariotoiny.  Every  one  understands  the  meaning  of  the 
term,  established  by  usage,  as  indicating  the  removal  of  the  ovaries 
when  the  subjects  of  morbid  growths.  Since  Dr.  Battey  introduced 
the  procedure  of  removing  the  normal  ovaries  the  term  oophorectomy 
has  been  used  more  frequently,  and  there  appears  to  be  a  disposition 
among  some  to  use  the  term  ovai'iotomy  when  speaking  of  the  re- 
moval of  ovarian  tumors,  and  oophorectomy  when  referring  to  the 
removal  of  the  ovaries  ^vhen  not  enlarged.  This  use  of  two  terms 
which  mean  exactly  the  same  thing  is  confusing  in  any  case,  but 
much  more  so  when  an  attempt  is  made  to  make  the  terms  indicate 
different  operations.  I  shall  use  the  term  ovariotomy  in  all  cases 
wlien  treating  of  the  removal  of  the  ovaries,  no  matter  what  their 
condition  may  be. 

Ovariotomy  has  in  the  past  been  the  term  used  for  the  operation 
which  includes  the  removal  of  the  Fallopian  tubes  with  the  ovaries. 
In  nearly  all  the  ovarian  tumors  the  Fallopian  tube  is  so  united  to 
the  neoplasm  that  removal  of  the  one  necessitates  the  removal  of  the 
other. 

The  o])eration  first  practiced  by  Tait  and  Hegar  of  removing  the 
tulx's  when  diseased  along  with  the  ovaries,  is  now  quite  generally 
spoken  of  as  removal  of  the  uterine  appendages.  This  is  a  very  un- 
satisfactory way  of  expressing  the  fact.  It  is  absurd  to  speak  of  the 
ovaries  and  tubes  as  ap])en(lages  of  the  uterus.  One  migiit  as  well 
speak  of  hysterectomy  as  the  removal  of  the  ovarian  appendage. 
Ill  the  evolution  of  development  the  uterus  is  added  to  the  ovaries 
and  tubes  in  the  higher  animals,  and  ovaries,  tubes,  and  uterus  have 
inde})endent  structures  and  functions ;  hence,  neither  one  is  an  ap- 
pendage to  the  other.  To  designate  the  operation  of  removing  the 
ovaries  and  Fallopian  tubes,  I  shall  use  the  term  tubo  ovariotomy. 

54^ 


OVARIOTOMY.  545 

GENERAL    CONSIDERATIONS    OF   OVARIOTOMY. 

Before  taking  up  the  details  of  the  operation,  I  shall  call  atten- 
tion to  certain  general  facts  which  belong  to  all  surgical  procedures, 
and  have  a  special  bearing  on  ovariotomy.  "While  most  that  vrill  be 
said  pertains  to  the  removal  of  ovarian  tumors,  it  will  be  equally 
applicable  to  the  removal  of  the  small-sized  diseased  ovaries  or  nor- 
mal ovaries  and  tubes,  the  more  modern  operation. 

I  have  long  entertained  the  opinion  that  ovariotomy  is  the  most 
difficult  operation  in  the  whole  field  of  surgery.  This  is,  however, 
a  matter  of  opinion,  and  may  be  an  error  on  my  part,  but  it  is  posi- 
tively certain  that  a  thorough  knowledge  of  surgery  and  all  attain- 
able dexterity  and  skill  in  operating  can  be  employed  with  advan- 
tage in  removing  ovarian  tumors.  This  operation  differs  from  all " 
others  that  I  know  of,  in  the  number  and  variety  of  complications 
which  it  affords.  It  is  seldom  that  two  cases  exactly  alike  occur  in 
the  practice  of  any  surgeon,  hence  it  is  not  until  a  very  large  num- 
ber of  cases  have  been  seen  that  the  operator  is  prepared  to  meet 
all  the  conditions  which  may  come  before  him.  To  the  operator  of 
limited  practice,  the  operation  in  this  respect  often  presents  the 
characteristics  of  a  new  investigation.  To  this  extent,  then,  the 
operation  is  unlike  anything  else  in  surgery.  Most  all  other 
operations  are,  to  a  great  extent,  definite ;  the  anatomy  being  the 
same  and  the  modus  ojoerandi  fixed  according  to  well-defined  rules. 
The  surgeon  has  it  in  his  power  to  learn  such  operations  by  practice 
upon  the  cadaver,  until  he  may  be  almost  master  of  his  work  (if  he 
has  in  him  the  surgical  diathesis)  before  touching  the  living  subject. 
No  such  opportunity  is  offered  to  acquire  the  art  of  doing  ovariot- 
omy. The  division  of  the  abdominal  walls,  the  first  and  simplest 
step  in  the  operation,  may  be  studied  and  practiced  upon  the  cada- 
ver, but  here  ends  the  value  of  dissection  as  a  special  aid  to  the  ova- 
riotomist. 

Books  and  lectures,  then,  are  the  most  available  sources  of  in- 
formation, but  this  reading  and  listening  to  others  talking,  although 
a  means  of  acquiring  a  knowledge  of  science,  is  a  poor  way  of  learn- 
ing how  to  perform  an  operation. 

It  is  true  that  one  may  familiarize  himself  vrith  all  the  steps  of 
an  operation  and  the  complications  which  may  be  found  in  each  case, 
and  he  may  be  able  to  recall  them  at  will,  and  think  of  them  clearly 
before  and  after  an  operation,  but  to  recognize  the  indications  and 
promptly  meet  them  while  operating,  can  only  be  learned  by  prac- 
tical observation. 
36 


546  DISEASES  OF  WOMEN. 

The  first  essential,  then,  is  to  know  how  to  operate — a  self-evident 
proposition  this,  which  need  not  be  made  here  were  it  not  for  the 
fact  that  many  try  to  perform  ovariotomy  who  are  not  qualified  to 
do  so.  It  is  a  notorious  fact  that  this  most  important  of  operations 
has  been  performed  by  many  who  had  no  claim  to  being  called  sur- 
geons. Obstetricians  who,  having  turned  their  attention  to  some  of 
the  plastic  operations  of  gynecology  and  succeeded,  have  next  taken 
to  ovariotomy.  A  few,  bolder  still,  have  made  their  debut  in  sur- 
gery as  ovariotomists,  without  any  previous  surgical  experience. 
Why  men  should  be  found  who  will  undertake  this  operation  while 
they  would  shrink  from  iridectomy  or  lithotomy,  is  a  difficult  ques- 
tion to  answer.  Perhaps  the  difliculties  in  the  way  of  learning  to 
do  this  operation  ma}^  account  for  it. 

It  is  clearly  evident  that  one  should  be  well  grounded  in 
the  science  and  art  of  surgery  before  taking  up  ovariotomy.  The 
consummate  surgeon  can  readily  transfer  his  art  to  this  department 
of  abdominal  surgery  with  far  more  hope  of  success  than  one  who 
seeks  to  acquire  skill  by  practicing  ovariotomy  as  his  maiden  effort. 

The  best  and  surest  way  of  all  to  qualify  for  this  operation  is  to 
secure  facility  in  general  surgery,  and  then  to  take  lessons  of  some 
successful  operator  ;  to  witness,  and  if  possible  to  assist  in,  a  sufficient 
number  of  operations  so  as  to  see  the  different  kinds  of  cases  and  the 
various  complications.  By  such  means  the  surgeon  can  secure  one 
great  element  of  success,  a  knowledge  of  manipulations.  Next  to 
knowing  how  to  operate  is  how  to  obtain  competent  assistants.  An 
operator  of  large  experience  may  be  able  to  do  the  operation  with 
assistants  who  know  little,  if  anything,  of  the  operation,  his  famil- 
iarity with  the  work  being  such  that  he  can  give  much  of  his  atten- 
tion to  those  who  are  helping  him,  and  so  command  success.  It  is 
quite  different  with  one  of  more  limited  experience.  His  whole 
time  and  attention  are  taken  up  with  that  which  he  is  doing  himself, 
and  if  his  assistants  are  unacquainted  with  their  duties,  they  gener- 
ally hinder  rather  than  help.  It  is  a  sad  sight  to  see  a  beginner, 
with  untrained  assistants,  trying  to  do  ovariotomy.  The  ease  with 
wliich  such  assistants  make  simple  things  complicated  and  lose  time 
in  hurrying  is  quite  extraordinary.  I  know  this  from  having  played 
the  role  of  operator  and  also  assistant  when  I  did  not  know  either 
of  the  parts. 

Skill  in  diagnosis  is  a  means  of  success  of  prime  importance, 
and  for  many  reasons  should  have  been  disposed  of  first ;  but  I  put 
the  operation  first  in  my  argument  simply  because  I  believe  that 
more  failures  come  from  poor  operating  than  from  errors  in  diagnosis. 


OVARIOTOMY.  547 

The  text-books  give  all  the  rules  and  means  of  diagnosis  so  fully 
that  no  one  needs  more  theoretical  instruction — but  here  again  much 
practice  is  needed.  Diseases  of  the  ovaries  present  such  variety  of 
physical  signs  that  a  very  large  experience  is  required  to  see  all  the 
different  kinds  of  cases.  Ovarian  tumors  differ  so  in  their  form, 
composition,  and  complications  in  the  way  of  adhesions,  that  their 
real  nature  is  difficult  to  make  out.  Again,  there  are  many  abdom- 
inal tumors  and  products  of  disease  which  simulate  in  their  physical 
signs  ovarian  tumors  so  closely,  that  ex]3erts  of  long  practice  are  at 
times  unable  to  make  a  correct  diagnosis.  Still,  great  accuracy  can 
be  attained  in  diagnosis  by  long  and  careful  observation.  In  many 
affections  we  can  successfully  adapt  our  treatment  to  the  deranged 
conditions  manifested,  although  the  exact  nature  of  the  pathology 
may  be  unknown  ;  but  in  ovarian  tumors  we  must  have  rather  definite 
ideas  of  their  character  before  we  can  begin  their  surgical  treatment. 

Ovariotomy,  as  an  operation,  differs  so  much  with  the  different 
operators,  both  as  regards  the  methods  of  procedure  and  results  ob- 
tained, that  I  propose  to  notice  some  of  the  conditions  upon  which 
the  success  apparently  depends. 

Dexterity  on  the  part  of  the  operator  and  all  available  means 
which  save  time  and  secure  accuracy  are  obvious  necessities,  and 
need  not  be  urged  in  this  connection.  In  an  operation  of  such 
magnitude  the  question  of  ansesthetics  requires  a  passing  notice. 
Sulphuric  ether  has  still  the  best  reputation.  Its  administration 
should  be  prompt  and  carefully  kept  up.  The  less  ether  that  the 
patient  takes  the  less  the  danger  and  the  better  the  condition  of  the 
patient  afterward.  Fifteen  or  twenty  minutes  wasted  in  antesthetiz- 
ing  give  just  so  much  unnecessary  blood-poisoning,  and  this  to 
some  extent  retards  recovery.  Giving  nitrous-oxide  gas  first,  and 
following  it  up  with  ether,  is  the  most  rapid  way  of  ansesthetizing. 
I  have  seen  this  method  employed  by  others  with  great  satisfaction. 
I  use  ether  altogether,  and  administer  it  with  the  apparatus  already 
described.  I  believe  that  the  great  majority  of  ovariotomists  use 
this  auEesthetic,  and  I  am  perfectly  satisfied  with  it  when  it  is  given 
in  the  way  that  I  have  mentioned 

There  are  a  number  of  points  of  importance  which  might  be 
discussed  in  this  connection  in  regard  to  the  different  methods 
which  surgeons  employ  in  performing  certain  steps  of  the  opera- 
tion. "When  describing  the  operation  I  shall  give  the  methods 
which  in  my  judgment  are  the  best,  but  a  general  discussion  of 
some  of  these  matters  appears  to  be  necessary  in  order  to  show 
reasons  for  my  preferences. 


548 


DISEASES  OF  WOMEN. 


In  the  management  of  the  pedicle,  for  example,  we  find  that 
even  the  renowned  operators  do  not  all  agree.  Through  the  influ- 
ence of  the  most  successful  of  all  operators,  I  am  firmly  convinced 
that  the  cautery  gives  the  best  results,  and  I  am  also  satisfied  that  it  is 
because  the  method  of  using  it  is  not  fully  understood  that  it  is  not 
more  generally  employed.  The  object  is  to  desiccate  at  least  half  an 
inch  of  the  end  of  the  stumj)  and  to  avoid  charring  it.  This  can 
only  be  accomplished  by  strongly  compressing  the  pedicle,  using  a 
heavy  clamp,  with  blades  half  an  inch  thick,  and  then  heating  it 


Fig.  222. — Cautery  clamp. 


with  a  very  heavy  cautery  until  the  portion  in  the  grasp  of  the  m- 
strument  is  thoroughly  desiccated.  The  stump  thus  treated  looks 
like  a  piece  of  translucent  horn.  The  divided  ends  of  the  vessels 
are  completely  closed,  which  guards  against  haemorrhage.  I  pre- 
sume that  the  end  of  the  stump  does  not  slongh,  but  becomes 
hydrated,  and  finally  organized. 

The  advantages  of  the  cautery  may  be  briefly  summarized  as 
follows  : 

It  is  a  reliable  way  of  controlling  htemori-hage ;  it  leaves  the  stump 
in  a  condition  requiring  the  least  rej^aratory  care ;  and,  finally,  it  avoids 
all  sources  of  irritation  such  as  that  to  which  the  ligature  gives  rise. 

I  have  recently  employed  a  cautery  clamp  which,  I  think,  has 
some  merits  worthy  of  notice.  It  compresses  the  pedicle  on  four 
sides.  The  long  blades  keep  the  tissues  from  spreading,  while  the 
short  sliding  blade  pi-csses  the  tissues  against  the  other  cross-bar. 
The  advantage  of  this  is  that  the  pressure  upon  the  pedicle  is  equal 
at  all  points,  and  it  thereby  gives  a  smaller  stump.  The  trouble 
with  the  old  straight  clamp  is,  that  it  spreads  out  the  pedicle  too 
much,  and  while  it  firmly  holds  the  central  or  thickest  part,  the 
outer  edges  are  liable  to  sli]>  out  of  its  grasp. 


OVARIOTOMY.  549 

The  next,  and  perhaps  the  most  important,  essential  of  success  is 
cleanliness,  or,  to  put  it  technically,  the  antiseptic  method  of  operat- 
ing. Surgeons  were  beginning  to  feel  a  certain  sense  of  security  in 
performing  ovariotomy  when  they  carried  out  all  the  details  of  the 
Listerian  method ;  but  more  recently  they  have  found  that  carbolic 
acid  in  place  of  saving  patients,  sometimes  sacrifices  them.  "When 
the  danger  of  carbolic-acid  spray  in  ovariotomy  was  first  announced 
many  surgeons  thought  that  Thomas  Keith  had  given  up  antiseptic 
surgery ;  but  that  great  surgeon  is  still  as  earnest  and  enthusiastic  in 
his  war  against  dirt  as  he  ever  was.  Although  he  has  given  up  the 
use  of  the  spray,  because  he  found  that  the  good  that  it  did  was 
counterbalanced  by  its  injurious  effects,  he  still  retains  all  the  other 
known  elements  of  antiseptic  surgery.  These  elements  I  under- 
stand to  be,  first,  to  keep  wounds  free  from  extrinsic  germs,  which 
are  in  themselves  injurious  to  living  tissues,  or  which  favor  morbid 
action  in  the  tissues  ;  and,  on  the  other  hand,  to  provide  for  the  es- 
cape of  morbid  material  which  may  be  developed  in  wounds.  To 
prevent  the  entrance  of  septic  germs  perfect  cleanliness  of  every- 
thing which  pertains  to  the  operation  is  necessary.  The  carbolic- 
acid  spray  can  at  most  only  disinfect  the  air  in  the  operating-room, 
and  consequently  it  is  only  one  fraction  of  the  antiseptic  method  of 
operating.  Clean  operators  and  assistants,  clean  instruments,  sponges 
and  everything  which  may  directly  or  indirectly  come  in  contact 
with  the  patient  before,  during,  and  after  the  operation,  are  all  of  the 
highest  importance.  Still  more,  it  is  absolutely  necessary  to  keep 
all  things  clean  during  the  operation.  A  clean,  fair  start  may  be 
made  ;  but  during  the  operation  the  operator's  hands  and  the  instru- 
ments may  become  contaminated  by  contact  with  the  contents  of 
the  cyst,  and  the  patient  be  exposed  to  septicaemia.  This  has  often 
occurred  when  the  spray  has  been  thoroughly  and  faithfully  used. 
Indeed,  if  too  much  dependence  is  placed  upon  the  spray,  there  is 
great  danger  of  contamination  from  want  of  care  in  other  respects. 
Some  of  the  fluid  contents  of  the  cyst  may  enter  the  abdominal  cav- 
ity, or  the  hands  of  the  operator  or  his  assistants  may  become  soiled 
from  the  same  source,  and  mischief  may  be  wrought  in  that  way. 
In  short,  it  is  exceedingly  difficult  to  guard  against  all  sources  of  un- 
cleanliness  in  this  complicated  operation.  I  think,  then,  that  if  all 
the  other  essential  elements  of  antiseptic  surgery  are  carefully  ob- 
served, the  spray  may  be  left  out  and  still  the  highest  success  can  be 
attained.  But  spray  or  no  spray,  too  much  can  not  be  said  in  favor 
of  antisepsis  in  relation  to  ovariotomy. 

There  is  still  another  fact  which  stands  out  prominently,  and 


550  DISEASES  OF  WOMEN. 

upon  which  success  depends,  and  that  is  the  management  of  the  dead 
material  which  maj  be  unavoidably  left  in  the  abdominal  cavity,  or 
that  may  accumulate  there  after  the  operation.  Blood  or  bloody 
serum  or  the  contents  of  the  cyst  that  may  be  left  or  may  accumu- 
late in  the  peritoneal  cavity  is  dangerous,  and  should  be  removed  by 
drainage. 

It  is  tme  that  within  the  last  year  or  two  there  has  been  some 
difference  of  opinion  regarding  the  value  of  drainage.  Some  of  the 
great  men  in  London  have  laid  it  aside  as  a  rule,  while  Keith  still 
employs  it  and  insists  that  he  saves  many  of  his  patients  by  it. 

I  believe  that  I  can  see  that  those  who  employ  drainage  have  the 
best  of  it.  I  incline  to  this  view  because  Keith,  who  practices  drain- 
age when  necessary,  has  had  the  highest  number  of  successes  ;  and 
because  the  reasoning  against  drainage  by  those  who  have  given  it 
up  does  not  appear  to  fully  harmonize  with  the  facts  in  the  case. 
It  is  claimed  that  if  ovariotomy  is  performed  with  all  the  attendant 
means  of  antisej^tic  surgery,  including  the  spray,  any  fluid  which 
may  be  left  or  that  may  accumulate  in  the  peritoneal  cavity  is  harm- 
less. Spencer  "Wells  states  that  fluids  do  not  accumulate  after  the 
use  of  antiseptics,  or  if  they  do  collect  they  do  not  putrefy,  but  are 
absorbed  without  injury. 

Now  it  is  difficult  to  understand  how  antiseptics  used  in  the 
operation  could  prevent  the  accumulation  of  serum  in  cases  where 
there  were  many  and  extensive  adliesions,  and,  on  the  other  hand,  it 
is  equally  incomprehensible  that  carbolic  acid  in  sufficient  quantity 
should  remain  in  the  abdominal  cavity  to  disinfect  the  fluids  which 
transude  from  broken  surfaces.  Without  daring  to  decide  the 
matter  or  to  express  any  positive  opinions,  I  may  state  that  the 
truth  appears  to  me  to  be  this :  Antiseptic  operating  will  lessen  the 
danger  to  a  very  great  degree,  but  there  will  always  be  cases  which 
call  for  drainage. 

The  value  of  drainage  depends  largely  upon  the  mode  of  using 
it.  The  method  which  I  have  usually  seen  practiced  in  this  country 
is  to  pass  a  tube  through  the  lower  angle  of  the  wound  down  into 
the  sac  of  Douglas,  and  then  to  close  its  outer  end  with  a  cork. 
This  cork  is  removed  several  times  a  day,  and  the  fluid  pumped  out. 
This  gives  a  kind  of  intermittent  drainage  which  is  very  imperfect. 
The  method  which  I  obtained  from  Dr.  Keith  is  much  better.  In 
place  of  closing  the  end  of  the  tube  he  passes  it  through  the  center 
of  a  piece  of  rubber  cloth,  and  then  places  a  carboUzed  sponge  upon 
the  end  of  the  tube.  The  rubber  cloth  is  folded  over  the  sponge, 
and  tied  securely  with  a  string.     The  tube  and  the  sponge  are  thus 


OVARIOTOMY.  551 

excluded  from  the  air,  and  any  fluid  which  accumulates  wells  up 
through  the  tube,  and  is  taken  up  by  the  sponge.  The  sponge  is 
changed  several  times  a  day,  and  any  residual  fluid  which  may  re- 
main is  pumped  out  at  each  dressing.  In  this  way  continuous  drain- 
age is  kept  up,  and  still  a  perfectly  antiseptic  dressing  is  maintained. 
This  may  appear  to  be  a  simple  matter,  but  it  constitutes  the  differ- 
ence between  perfect  and  imperfect  drainage.  In  a  case  operated 
upon  last  summer,  I  obtained  twelve  ounces  of  fluid  in  thirty-six 
hours  by  this  method  of  drainage,  and  the  temperature  of  the  pa- 
tient never  rose  above  normal,  excepting  one  day  when  it  reached 
one  hundred,  and  remained  there  for  a  few  hours.  This  case  alone 
would  be  sufficient  to  demonstrate  both  the  safety  and  value  of 
drainage. 

In  addition  to  the  requisite  skill  in  diagnosticating  ovarian  tu- 
mors, it  is  highly  essential  to  success  to  make  a  correct  estimate  of 
the  patient's  general  condition  before  operating. 

Preparatory  Treatment  for  Laparotomy. — One  meets  not  infre- 
quently with  urgent  cases  which  must  be  taken  as  they  are  and 
operated  upon  at  once.  The  majority  of  cases,  however,  can  be 
kept  under  observation  long  enough  to  obtain  a  clear  idea  of  their 
characteristics.  When  the  diagnosis  of  the  local  condition  is  made, 
the  general  state  of  the  patient  should  be  carefully  examined  into. 
The  advantage  accruing  from  acting  on  this  principle  was  recently 
impressed  upon  my  mind  in  a  case  of  a  large  fibro-cystoma  of  the 
uterus  which  required  removal  While  under  preparatory  treat- 
ment the  patient's  temperature  rose  to  103-|^°  F.,  and  there  was  much 
pain  in  the  abdomen.  Septic  peritonitis  was  suspected,  but  the 
temperature  came  down  and  again  went  up,  showing  that  the  trouble 
was  a  zymotic  one,  and  it  yielded  promptly  to  the  use  of  quinine. 
Had  I  operated  without  knowing  that  the  patient  was  disposed  to 
this  form  of  fever,  I  doubt  if  she  would  have  recovered  as  promptly 
as  she  did. 

The  Nervous  System. — The  state  or  condition  of  the  nervous 
system  should  be  investigated,  and,  if  found  defective,  should  be  cor- 
rected as  far  as  possible.  Many  patients  leave  home  to  be  under  the 
care  of  the  special  surgeon,  and  this,  together  with  the  dread  of  the 
treatment,  often  deranges  the  nervous  system.  All  this  can  be  over- 
come, usually,  while  other  preparatory  treatment  is  instituted.  Time 
should  be  given  for  the  patient  to  become  accustomed  to  her  sur- 
roundings and  to  gain  confidence  in  the  nurse  and  surgeon.  Dur- 
ing this  time  the  true  state  of  her  nervous  system  can  be  ascertained. 
If  she  is  sleepless  and  depressed,  relief  should  be  given  by  nerve 


552  DISEASES  OF  WOMEN. 

sedatives  and  tonics.  Quite  often  the  damaged  state  of  the  nervous 
system  is  due  to  impaired  nutrition,  and  will  be  relieved  by  improv- 
ing the  digestion.  Occasionally  the  nervous  trouble  is  primary,  and 
requires  direct  attention.  Opium  in  small  doses  is  most  reliable  in 
producing  sleep  and  relieving  depression,  but  it  deranges  digestion 
and  nutrition  in  some  cases,  and  on  that  account  other  remedies 
should  be  employed.  Sulphonal  does  remarkably  well  as  a  sleep- 
producer,  and  is  much  preferable  to  bromide,  chloral,  or  any  com- 
bination of  these  remedies.  It  produces  the  desired  result  in  the 
great  majoi'ity  of  cases  that  are  not  kept  from  sleep  by  severe  pain. 
This  remedy  is  worthy  of  note  as  rather  new,  and  is  certainly  one 
that  will  cause  sleep  with  no  other  j^erceptible  effect,  good  or  bad. 

To  restless,  anxious  patients,  who  find  the  days  very  long  even 
when  they  sleep  at  night,  and  on  whom  opium  does  not  act  well, 
I  have  given  large  doses  of  lupulin  and  small  doses  of  cannabis 
Indica.     If  these  do  not  answer,  opium  should  be  tried. 

One  of  the  greatest  advantages  of  this  preparatory  treatment  is 
that  the  effect  of  opium  on  the  case  in  hand  can  be  observed,  so  that, 
if  it  becomes  necessary  to  use  it  in  the  after-treatment,  the  surgeon 
knows  how  far  to  depend  upon  it  and  what  effects  may  be  expected. 

The  Nutritive  System. — This  requires  attention  in  all  patients. 
In  the  majority,  nutrition  is  impaired  because  of  derangement  of  the 
digestive  organs.  In  others  the  general  nutrition  is  good,  while  the 
digestive  organs  alone  are  at  fault. 

The  time  during  which  the  trouble  calling  for  surgical  treat- 
ment has  existed  makes  the  difference  in  the  general  condition  of 
the  patients. 

There  are  two  classes  of  patients  usually  met  in  practice  who  re- 
quire attention  in  regard  to  digestion  and  general  nutrition :  First, 
those  who  have  not  been  long  under  the  influence  of  the  affection, 
and  need  very  little  treatment,  except,  perhaps,  to  relieve  consti- 
pation and  subacute  indigestion  Such  cases  are  often  left  with- 
out any  preparatory  treatment  save  a  cathartic  the  day  before  the 
operation.  This  may  be  safe  enough,  but  in  the  majority  of  cases 
the  tongue  is  coated,  the  bowels  sluggish,  the  appetite  variable,  and 
the  kidneys  act  imperfectly.  These  conditions  can  all  be  relieved 
by  a  few  small  doses  of  the  mild  chloride  of  mercury,  followed  by  a 
saline  laxative.  If  this  does  not  clear  the  tongue,  improve  the  state 
of  tlic  stomach,  and  increase  the  action  of  the  kidneys,  the  treatment 
should  be  repeated  in  a  few  days.  Second,  the  more  advanced  cases, 
in  which  there  is  general  mal-nutrition  as  well  as  impaired  digestion. 
These  require  more  care  and  for  a  longer  time.     It  sounds  well  to 


OVARIOTOMY.  553 

say  of  sucli  patients  tliat  the  cause  being  tlie  neoplasm,  if  tliis  is  re- 
moved the  mal-nutrition  will  be  cnred ;  bnt  the  chance  of  the  patient 
being  able  to  stand  the  operation  may  be  improved  by  overcoming 
the  constitutional  derangements  as  far  as  that  is  possible.  Gas- 
tric sedatives,  such  as  bismuth  or  cerium,  may  relieve  the  irritation 
and  improve  the  appetite,  and  tonic  laxatives,  such  as  nux  vomica, 
belladonna,  and  rhubarb,  will  relieve  constipation  far  better  than 
salines. 

Management  of  the  Bowels. — The  objects  in  view  in  the  man- 
agement of  the  bowels  are  threefold  :  First,  to  clear  out  the  canal ; 
second,  to  establish  as  far  as  possible  normal  secretion  ;  and,  third, 
to  remove  the  causes  of  flatulence,  whatever  they  may  be.  A 
cathartic  should  be  given  two  days  before  the  operation.  In  the 
choice  of  a  laxative  or  cathartic,  one  should  be  sought  which  will 
meet  all  these  indications.  In  cases  showing  deranged  secretion,  in- 
dicated by  the  state  of  the  tongue  and  appetite,  an  alterative  dose  of 
mercury  should  precede  the  cathartic,  as  already  suggested.  The 
mercury,  being  a  reliable  disinfectant,  will  also  meet  another  indica- 
tion, the  relief  of  flatulence.  The  selection  of  a  cathartic  to  be  given 
just  before  the  operation  is  important.  Castor  oil  is  the  best  in  case 
there  is  constipation  or  a  suspicion  of  faecal  impaction.  The  only 
difficulty  is  that  many  patients  strongly  object  to  it.  When  it  can  be 
taken,  it  should  be  given  two  nights  before  the  operation.  This 
gives  time  for  the  oil  to  act,  and  also  gives  the  bowels  a  chance  to  be- 
come quiet.  The  rectum  should  be  washed  out  the  night  before  the 
operation  or  early  in  the  morning.  In  feeble  patients  who  require 
a  cathartic  and  yet  are  not  strong  enough  to  stand  its  operation,  I 
give  half  an  ounce  of  castor  oil  and  two  drachms  of  oil  of  turpen- 
tine. This  is  a  most  valuable  preparation,  if  the  stomach  will  retain 
it.  In  fact,  this  is  the  only  cathartic  that  will  act  thoroughly  in 
weak,  debilitated  patients  without  causing  depression.  The  dose  of 
turpentine  is  large,  but  if  less  is  given  it  will  affect  the  kidneys  and 
fail  as  a  cathartic  to  some  extent.  This  may  be  called  a  tonic  or 
stimulant  and  cathartic.  A  similar  effect  may  be  obtained  by  giving 
six  grains  of  rhubarb,  one  grain  of  compound  extract  of  colocynth, 
one  grain  of  camphor,  and  a  tenth  of  a  grain  of  extract  of  bella- 
donna, in  pills.  There  is  a  little  depression  following  the  action  of 
this,  but  it  is  not  so  certain  in  its  action  as  oil  and  turpentine. 

To  those  who  can  not  take  either  oil  or  pills  without  having  their 
stomachs  upset,  I  give  one  or  two  teaspoonfuls  of  calcined  magnesia 
and  half  a  teaspoonful  of  charcoal,  followed  in  a  few  minutes  M'ith  a 
glass  of  warm  lemonade.    This  empties  the  bowels  and  relieves  flatu- 


554  DISEASES  OF  WOMEN. 

lence  very  tlioroughly.  This  is  given  in  the  morning  of  the  day 
before  the  operation,  the  object  being  to  have  the  bowels  quiet  and 
empty  at  the  time  of  operating. 

The  condition  of  the  heart  and  kidneys  should  be  carefully  no- 
ticed, especially  that  of  the  kidneys.  The  urine  should  be  thorough- 
ly examined  before  giving  an  anaesthetic.  I  am  satisfied  that  disease 
of  the  kidneys  is  the  most  important  of  the  contra-indications  to  the 
use  of  anaesthetics.  If  any  renal  disease  is  found,  it  should  be  care- 
fully treated  and  watched,  and,  if  it  proves  to  be  acute  or  subacute, 
sufficient  relief  can  in  time  be  obtained  to  warrant  the  operation ; 
but  chloroform  might  be  chosen  in  place  of  ether  as  the  angesthetic, 
and  extra  efforts  should  be  made  to  shorten  the  time  of  operating. 
I  have  for  a  long  time  made  it  a  rule  to  examine  the  urine  always 
before  giving  an  aneesthetic,  and  believe  that  it  sliould  be  the  invari- 
able practice  to  do  so.  I  refer  to  that  matter  here  because  I  have 
found  many  who  do  not  think  it  necessary. 

In  regard  to  the  state  of  the  heart,  I  find  that  it  is  often  de- 
ranged in  its  function  from  pressure  or  indigestion,  and  it  nearly 
always  improves  under  treatment.  When  there  is  time,  I  order 
muscular  exercise  as  well  as  remedies  to  improve  nutrition,  and  find 
that  much  improvement  in  the  heart  action  follows.  Organic  heart 
disease,  other  than  extreme  hypertrophy,  moderate  dilatation,  or 
aortic  stenosis  or  insufficiency,  does  not  deter  me  from  giving  an 
anaesthetic  and  operating.  Many  cases  having  disease  of  the  mitral 
valve  take  ether  very  well. 

The  day  and  evening  before  the  operating  day  call  for  certain 
attentions.  The  bath  so  generally  given  the  night  preceding  the 
operation  is  not  always  advisable.  If  the  patient  is  used  to  daily  or 
frequent  bathing  it  may  be  safe  to  give  it,  but  otherwise  it  is  dan- 
gerous. The  patient  may  get  cold  or  become  exhausted.  The  loath- 
ing should  be  done,  in  such  cases,  several  days  before,  and  then  with 
great  care.  When  there  is  marked  debility,  with  weak  lieart,  digi- 
talis and  nux  vomica  should  l)e  given  the  preceding  day ;  especially 
is  this  necessary  when  the  operation  promises  to  be  a  bad  one.  I 
formerly  gave  quinine,  believing  that  it  was  a  good  tonic  and  helped 
to  prevent  shock,  but  I  am  satisfied  that  digitalis  and  nux  vomica 
are  better.  The  number  of  doses  should  depend  upon  the  effect. 
As  soon  as  the  heart  action  is  noticeably  improved  the  drugs  should 
be  withheld. 

The  food  should  be  of  the  most  nourishing  kind,  and  at  the 
same  time  easily  digested,  or  else  it  should  be  artificially  digested. 
Sterilized  or  peptonized  milk,  clear  soups,  tender  beef,  mutton,  eggs, 


OVARIOTOMY.  555 

and  raw  oysters,  either  or  all  of  these,  according  to  the  preference 
of  the  patient,  may  be  used. 

The  time  to  operate  is,  as  a  general  rule,  midway  between  the 
menstrual  periods.  An  exception  should  be  made  in  cases  of  menor- 
rhagia  and  dysmenorrhoea,  in  which  there  is  an  improvement  in  the 
strength  toward  the  period  of  menstruation.  Advantage  should  be 
taken  of  that  temporary  improvement  by  operating  immediately  be- 
fore the  menses. 

The  morning  is  by  far  the  best  time  to  operate.  The  patient  is 
then  at  her  best,  and  the  stomach  is  empty — a  condition  very  neces- 
sary to  the  taking  of  an  anEesthetic.  This  would  not  be  referred  to 
here  were  it  not  for  the  fact  that  a  great  many  surgeons  in  this  coun- 
try operate  late  in  the  day.  There  are  many  disadvantages  in  doing 
so.  The  patient  suffers  from  anxious  anticipation,  and  becomes  fa- 
tigued if  food  is  not  given  ;  and  if  it  is  given,  it  is  not,  as  a  rule, 
either  digested  or  absorbed,  and  the  stomach  acts  badly  during  and 
after  the  ansesthssia  under  such  circumstances. 

I  am  led  to  dwell  a  moment  on  the  general  therapeutics  of  ab- 
dominal section,  for  the  reason  that  my  attention  and  that  of  my  as- 
sistants has  been  so  fully  engrossed  with  the  details  of  antisepsis  and 
the  technique  of  the  operation,  that  many  important  items  in  the 
general  therapeutics  have  been  at  times  overlooked.  It  is  likely 
that  a  similar  experience  may  fall  to  the  lot  of  others. 

There  are  certain  points  in  the  management  of  the  patient  dur- 
ing the  operation  which  may  be  briefly  mentioned. 

The  patient  should  be  kept  warm,  but  the  room  should  be  cool, 
not  over  Y0°  F.  A  very  warm  room  has  been  advised,  and  there 
are  many  surgeons  who  still  prefer  it,  believing  that  there  is  dan- 
ger of  chilling  the  patient  by  exposing  the  abdominal  organs  to  cool 
air.  This  can  be  obviated  in  other  ways,  by  keeping  the  patient's 
head  and  feet  warm  by  hot  water  if  need  be,  and  protecting  the 
trunk  with  rubber  cloth.  Chilling  the  peritonaeum  is  avoided  by 
the  use  of  warm  sponges.  One  large  sponge  should  be  placed  in 
the  wound  as  soon  as  the  tumor  is  removed.  This  prevents  the  es- 
cape of  the  intestines,  and  protects  the  peritonaeum  from  the  air. 
The  sponges  are  maintained  at  the  proper  temperature  by  being  kept 
in  a  pail  which  is  placed  in  a  larger  one  filled  with  hot  water.  The 
sponges  are  thus  kept  dry,  while  the  water  in  the  chamber  around 
the  inner  pail  keeps  up  the  warmth.  In  case  the  operation  is  a 
long  one,  the  water  surrounding  the  sponge-pail  can  be  renewed. 

Warm  ether  is  also  of  value  in  avoiding  shock  and  chilling  the 
patient.     This  is  obtained  by  using  my  ether-inhaler,  in  which  the 


556 


DISEASES  OF  WOMEN. 


ether  is  vaporized  in  a  reservoir  and  conveyed  to  the  patient  throngh 
a  rubber  tube.  This  warms  the  ether  sufficiently  to  make  it  agree- 
able and  safe.  I  have  on  former  occasions  spoken  of  the  advantages 
of  this  ether-inhaler,  by  which  the  anaesthetic  can  be  given  pure,  or 
diluted  with  pure  air  to  any  degree,  and  without  the  reinspiration 
of  the  expired  air.  I  may  add  here  that  experience  only  tends  to 
confirm  my  confidence  in  that  method  of  using  an  anaesthetic  such 
as  sulphuric  ether. 

List  of  Instruments  and  Appliances  'usually  required  in  the 
Operation. — Scalpel  with  fixed  handle ;  dissecting-forceps ;  artery- 


FiG.  223. — Keith's  short  compression-forceps. 


forceps ;  six  Keith's  compression-forceps  (Figs.  223  and  224) ;  one 
vulcellum  forceps;  one  fenestrated  forceps;  small,  straight,  blnut- 
pointed  scissors ;  large,  straight  scissors ;  trocar  and  rubber  tube. 


Fig.  224. — Keith's  long  compression-forceps 


These  are  placed  together  in  an  enameled  pan  filled  half -full  with 
a  one-to-forty  carbolic-acid  solution. 

Twelve  to  twenty  sponges,  the  exact  number  to  he  carefully  noted., 
prepared  and  placed  in  a  double  tin  pail  with  hot  water  in  the  outer 
compartment;  six  towels  soaked  in  a  one- to-twenty  carbolic  solution, 
and  put  in  the  sponge  pail ;  No.  1,  3,  and  11  prepared  silk  for  liga- 
tures. 

These  should  be  cut  the  proper  length  for  ligating  thick  adhe- 
sions and  the  pedicle,  and  wrapped  in  gauze  and  put  into  the  car- 
bolic solution. 

No.  4  silk  for  the  abdominal  sutures  should  be  prepared  in  the 
same  way  ;  No.  2  catgut  ligatures ;  Keith's  needles,  two  for  each  ab- 


OVARIOTOMY. 


557 


dominal  suture  (Fig.  225) ;  Peaslee's  needles ;  Keith's  fine  forceps 
for  carrying  the  Hgatures  (Fig.  226)  through  the  pedicle  ;  sutures  to 

— —    -       -TIT  iirrrr-n-.-r     -  -   iiB» 

Fig.   225. — Keith's  needle. 

be  used  with  Peaslee's  needle  if  required ;  a  sheet  of  rubber  cloth, 
three  by  four  feet,  with  an  oval  hole  in  the  center,  the  border  of 
which  is  coated  with  sticking-plaster  an  inch  wide  all  around  ;  long 


226. — Keith's  ligature  forceps. 


straps  of  saddle-girth  to  fasten  the  patient's  limbs  to  the  table  ;  a  yard 
of  gauze  or  cheese-cloth  soaked  in  a  solution  of  one  part  of  carbolic 
acid  to  eight  of  glycerin  for  a  dressing ;  sheet  of  absorbent  cotton 
large  enough  to  cover  the  abdomen  ;  flannel  bandage  ;  safety-pins, 

Instrumeoits  and  Appliances  that  may  he  needed. — Cautery 
clamps ;  cautery  irons ;  Keith's  clamp  (Fig.  227) ;  curved  scissoi's ; 
concave  mirror ;  counter-pressure  instrument  for  tying  ligatures  in 
abdominal  cavity ;  several  drainage-tubes  of  different  sizes ;  piece  of 


-s^rEvSfNS^xtJ.— ^" 


Fig.  227. — Keith's  modification  of  Spencer  Well's  clamp. 

sheet-rubber,  ten  by  ten  inches,  to  cover  the  end  of  tlie  drainage- 
tubes ;  twelve  or  more  extra  sponges;  twelve  to  twenty  extra  com- 
pression-forceps ;  aspirator  ;  elastic  ligature. 

These  should  be  clean  and  placed  within  reach  of  the  operator, 
but  not  mixed  with  the  other  instruments  named. 

The  instruments  to  be  used  should  be  placed  on  a  stand  beside 
the  operator,  and  also  a  basin  with  carbolic  solution,  or  such  disin- 
fectant as  the  surgeon  chooses  to  use  for  keeping  the  hands  clean. 


558 


DISEASES  OF   WOMEN. 


The  sponges,  ligatures,  towels,  and  dressings  maj  be  placed  beside 
tbe  first  assistant 

Assistants. — Three  assistants  are  certainly  needed,  and  one  more 
may  be  required.  One  gives  the  ether,  one  stands  on  the  left  side 
of  the  patient,  facing  the  operator,  the  third  on  the  left  of  the  op- 
erator, and  the  fourth  one  attends  to  the  washing  of  the  sponges. 

The  chief  assistant  on  the  opposite  side  of  the  table  sponges  tlie 
wound  during  the  incision  of  the  abdominal  walls,  holds  the  vessels 
or  adhesions  when  the  operator  is  ligating  them,  supports  the  cyst 
when  brought  out,  helps  to  apply  the  sutures  to  the  wound,  and  ful- 
fills all  orders  of  the  operator.  The  second  assistant  supports  the 
abdomen  and  cyst  or  tumor  while  the  abdominal  walls  are  being 
opened,  and,  when  the  cyst  is  being  removed,  he  helps  to  expel  it 
by  pressure,  and  at  the  same  time  prevents  the  escape  of  the  ab- 
dominal viscera. 

The  assistants  carry  the  patient  from  the  bed  to  the  table.  A 
blanket  is  wrapped  around  her  limbs,  and  a  rubber  bag  of  hot  water 


JF^^B^ 


,BTAND,    WITH    INSTRUMENTS   AND    BASINS/) 


It^^i 


Fig.  228. — Position  of  operator,  assistants  ami  accessories  in  the  operation.     Both  arms 
should  lie  close  to  the  patient's  side. 

placed  at  her  feet.  The  strap  is  passed  over  the  thighs  and  around 
the  table.  The  abdomen  is  made  l)are  by  opening  the  dressing-gown 
and  raising  the  undergarment.     The  rubber  cloth  is  spread  over  the 


OVARIOTOMY.  559 

patient,  and  the  edges  of  the  opening  in  the  center  stuck  fast  to  the 
skin  around  the  lower  and  central  portions  of  the  abdomen.  One  of 
the  carbolized  towels  is  laid  over  the  thighs  of  the  patient,  upon 
which  are  placed  the  instruments  which  are  first  to  be  used.  This 
diagram  will  show  at  a  glance  the  position  of  all  concerned. 
The  several  steps  of  the  operation  are  as  follows : 

1.  Making  the  incision  in  the  abdominal  wall. 

2.  Exploring  for  adhesions. 

3.  Tapping  the  cyst  or  cjsts. 

4.  Treating  adhesions  and  removing  tumor. 

5.  Treating  the  pedicle. 

6.  Examination  and  treatment  of  the  other  ovary. 

7.  Cleansing  the  abdominal  cavity. 

8.  Closing  the  incision. 

9.  Dressing  the  abdominal  wound  and  placing  the  patient  in  bed. 
The  details  of  the  several  steps  in  the  operation  in  uncomplicated 

cases  are  as  follows : 

The  incision  is  made  in  the  linea  alba — traces  of  which  can  usu- 
ally be  seen — down  to  the  muscular  layer.  The  length  of  the  incis- 
ion should  be  about  three  inches,  extending  from  one  inch  above 
the  pubes  upwards.  The  assistant  should  follow  the  knife  with  the 
sponge,  and  any  bleeding  vessels  should  be  caught  up  in  plain  for- 
ceps. The  tissues  at  the  bottom  of  the  wound  should  be  picked  up 
with  a  dissectiug-forceps,  and  an  opening  made  in  the  median  hne 
with  the  knife,  the  edge  of  which  should  be  directed  away  from  the 
tumor.  When  making  this  opening  care  should  be  taken  to  find 
the  median  line  between  the  muscles.  This  is  often  done  at  the  first 
trial,  but,  if  the  muscle  is  exposed,  its  sheath  should  be  followed  in 
either  direction  until  the  median  line  is  found,  and  then  another 
opening  made  there.  The  knife  is  then  put  aside,  and  one  blade  of 
the  blunt-pointed  scissors  is  introduced  into  the  opening,  and  the 
incision  completed  by  cutting  in  both  directions.  This  usually  ex- 
tends through  the  muscular  layer ;  the  fascia  and  the  peritonaeum 
still  remain.     These  should  be  opened  in  the  same  manner. 

A  sound,  finger,  or  the  whole  hand  may  be  introduced  to  de- 
termine the  presence  and  character  of  adhesions,  if  such  exist.  The 
trocar  and  cannula  are  then  plunged  into  the  cyst  at  the  highest  end 
of  the  incision,  the  trocar  drawn  back  and  handed  to  the  assistant,  who 
takes  care  that  fluid  does  not  enter  the  abdominal  cavity.  The  cyst- 
wall  should  be  seized  with  a  lock-forceps  between  the  cannula  and 
left  side  of  the  incision.  This  is  also  handed  to  the  assistant,  who 
holds  it  and  the  trocar  in  his  left  hand,  and  makes  the  necessary 


560  DISEASES  OF   WOMEN. 

traction  to  withdraw  the  cyst,  which  he  grasps  with  his  right  hand 
when  it  comes  out,  and  holds  it  without  making  traction  upon  the 
pedicle. 

The  operator  pushes  a  sponge  into  the  wound  behind  the  tumor. 
The  pedicle  is  then  examined  to  ascertain  its  size  and  character,  and 
whetiier  it  be  twisted.  The  cautery  clamp  (if  that  method  of  treat- 
ing the  pedicle  is  to  be  practiced)  is  then  applied,  and  the  pedicle  di- 
vided within  half  an  inch  of  the  clamp.  The  operator  then  sponges 
the  abdominal  cavity,  taking  special  care  not  to  leave  any  fluid  be- 
tween the  bladder  and  the  uterus.  The  assistant  meantime  takes 
care  of  the  clamp.  The  operator  examines  the  other  ovary,  and 
decides  whether  it  requires  to  be  also  removed  or  not.  One  or  more 
sponges  are  left  in  the  abdomen  while  the  pedicle  is  being  treated 
with  the  cautery.  Two  carbolized  towels  are  placed  under  the  clamp, 
and  the  remains  of  the  pedicle  are  removed  with  the  cautery.  The 
clamp  is  then  loosened  a  very  little  by  unscrewing,  and  the  cautery 
applied  until  the  clamp  is  heated  throughout  to  a  degree  that  will 
admit  of  the  tinger  being  firmly  placed  upon  it.  Before  finishing 
the  cauterizing,  the  clamp  should  be  screwed  up  tight.  While  the 
cauterizing  is  being  done,  the  assistant  should  remove  all  fluid  and 
dehrls  with  a  sponge  and  forceps,  and,  if  the  towels  beneath  the 
clamp  become  heated,  they  should  be  changed.  The  clamp  should 
be  cooled  with  a  moist  sponge  without  touching  the  cauterized  edge. 
The  pedicle  is  then  seized  with  two  forceps  below  the  clam];),  which 
is  gradually  and  with  great  care  loosened.  The  stump  of  the  pedi- 
cle should  be  watched  for  a  few  seconds  to  see  if  the  blood  inclines 
to  pass  up  any  of  the  vessels  in  the  part  that  has  been  cauterized. 
If  there  is  no  sign  of  such  taking  place,  then  the  stump  is  dropped 
back  and  covered  with  intestines,  and  the  omentum  over  all.  Should 
the  operator  decide  to  ligate  in  place  of  using  the  cautery,  the  pedi- 
cle is  secured  by  two  compression-forceps,  and  a  doul)le  ligature  is 
passed  through  the  center  of  the  pedicle  with  a  Keith's  ligature- 
forceps,  and  ligated  in  two  halves.  Care  should  be  taken  to  cross 
the  ligatures,  so  that  when  the  two  are  tied  they  will  draw  the  tis- 
sues together  in  one  mass.  When  the  pedicle  is  small  and  long, 
it  can  be  tied  before  cutting  away  the  cyst,  and  without  using  a 
clamp  at  all.  The  sponges  should  be  recounted  at  this  stage  of  the 
operation,  to  make  sure  that  none  is  loft  in  the  abdominal  cavity — 
ail  accident  which  has  occasionally  happened. 

A  flat  sponge  is  placed  over  the  omentum  and  beneath  the  edges 
of  the  wound,  and  left  there  while  the  sutures  are  being  introduced. 
All  bleeding  vessels  in  the  abdominal  wall  should  be  ligated.     Two 


OVARIOTOMY.  561 

Keith's  needles  are  used  for  each  suture,  one  at  each  end.  The 
needles  are  introduced  from  the  inside  of  the  abdominal  wall,  and 
include  the  peritonjEum.  This  method  of  introducing  the  sutures 
is  the  quickest  and  the  best  when  the  incision  is  long  or  medium  in 
length,  but  when  the  ihfcision  is  short  I  prefer  to  use  Peaslee's  needle 
of  smaller  size  than  that  which  is  usually  found  in  the  shops.  The 
needle  is  passed  from  without  inward,  and  the  suture  is  carried 
through  the  double  of  the  thread  in  the  needle,  and,  as  the  needle 
is  withdrawn,  the  suture  is  brought  into  place.  Having  introduced 
all  the  sutures,  the  ends  on  each  side  are  gathered  together  and  held 
while  the  flat  sponge  is  removed.  The  air  should  be  pressed  out  of 
the  abdominal  cavity,  and  the  sutures  tied.  Slip-knots  are  prefera- 
ble. The  sutures  should  be  close  together,  about  four  to  the  inch. 
Here  and  there  a  superficial  suture  may  be  needed  to  make  the  co- 
aptation as  complete  as  it  should  be.  The  dressing  of  gauze,  soaked 
in  the  one-to-eight  solution  of  glycerin  and  carbolic  acid,  is  applied, 
and  over  that  absorbent  cotton  and  a  flannel  bandage.  The  patient 
is  put  into  a  warm  bed,  and  hot  water-bags  or  bottles  put  around 
her,  and  one  sixth  or  one  quarter  of  a  grain  of  morphine  given  hypo- 
dermically. 

Comjjlications. — The  several  steps  in  the  operation  are  liable  to 
be  complicated  by  a  variety  of  conditions.  The  chief  of  these  may 
be  mentioned  in  the  order  in  which  they  come. 

When  there  is  much  fat  beneath  the  skin  it  is  diificult  to  make 
a  straight  incision.  In  that  condition  the  wall  may  be  grasped  in 
the  left  hand,  raised  up  and  transfixed  with  the  bistoury  and  divided 
from  within  outward.  This  leads  down  at  once  to  the  muscular 
layer,  and  then  the  incision  is  finished  in  the  usual  way.  Great 
vascularity  of  the  abdominal  wall,  while  easily  managed,  takes  time. 
One  or  two  bleeding  vessels  may  be  caught  in  plain  forceps  and  con- 
trolled, but  when  there  are  many  it  is  better  to  tie  them  because  a 
number  of  compression-forceps  are  in  the  way  during  the  operation. 

Firm  adhesions  of  the  tumor  to  the  abdominal  wall  in  the  line  of 
incision  are  often  a  troublesome  complication,  which  leads  the  opera- 
tor either  to  open  into  the  sac  before  knowing  it,  or  else  to  sepa- 
rate the  peritonaeum  from  the  abdominal  walls.  When  the  tumor 
can  once  be  reached  at  any  one  point,  it  is  very  easy  to  separate  the 
adhesions,  but  it  is  often  diflicult  to  get  that  one  point.  Enlarging 
the  incision  is  a  help,  and  it  should  be  carried  in  the  direction  up  or 
down  according  to  the  possibility  of  reaching  a  point  where  the  cyst 
is  free.     Sometimes  the  exudation  which  forms  the  adhesion  can  be 

recognized  when  it  is  reached;  it  is  then  easy  to  follow  it  up  until 
37 


562  DISEASES  OF   WOMEN". 

the  detachment  is  complete.  "When  the  cyst  is  exposed  all  the  par- 
ietal adhesions  should  be  loosened.  This  should  be  done  by  the 
hand.  When  the  tumor  has  been  of  slow  growth  and  is  tense  and 
tlie  walls  opparently  thick  and  strong,  a  very  great  amount  of  force 
can  be  used  in  separating  adhesions. 

If  the  tumor  is  flaccid  it  is  well  to  steady  it  with  a  pair  of  for- 
ceps while  separating  the  adhesions  and  before  introducing  the 
trocar. 

Parietal  adhesions  are  treated  before  tapping  the  cyst,  at  least  as 
far  as  they  can  be  easily  reached  by  the  hand. 


EMPTYING    THE    TUMOR    IN    COMPLICATED    CASES. 

In  multiple  cyst  and  multilocular  cases  in  which  the  contents 
of  the  sac  can  be  removed  by  tapping,  the  trocar  and  cannula  are 
thrust  into  the  nearest  cyst  and  it  is  emptied  in  the  usual  way  ;  the 
trocar  is  then  pushed  into  another  sac,  which  in  turn  is  emptied, 
and  so  on,  until  all  are  emptied.  To  do  this  safely  the  tumor  should 
be  steadied  w^ith  the  left  hand,  while  the  trocar  is  used  with  the 
right,  and  this  helps  to  make  sure  that  the  trocar  goes  into  the  sac 
and  not  into  the  viscera  or  abdominal  walls. 

When  the  contents  of  the  tumor  are  semi-solid  and  will  not  flow 
through  the  cannula,  the  trocar  and  cannula  should  be  removed, 
and  the  opening  in  the  sac  enlarged  in  the  axis  of  the  body  ;  i.  e., 
the  opening  should  correspond  to  the  opening  in  the  abdominal 
wall.  A  pair  of  forceps  should  be  fastened  near  each  end  of  the 
opening  on  the  left  side,  and  perhaps  a  small  one  at  the  lower  end 
on  the  right'  side.  These  forceps  are  held  by  the  assistant,  and  as 
the  tumor  becomes  smaller  he  draws  the  sac  out  and  down  until 
the  opening  in  the  sac  is  below  the  level  of  the  opening  in  the 
abdomen.  The  operator  introduces  his  hand  through  this  large 
opening  into  the  cyst  that  is  emptied,  and  breaks  down  the  other 
cyst-walls  and  sweeps  them  out ;  while  the  finger  of  the  right  hand 
is  boring  through  the  cyst- walls  the  tumor  is  steadied  with  the  left 
hand  on  the  abdominal  wall.  In  this  way  the  contents  of  large  tu- 
mors may  be  broken  down  and  removed.  While  this  is  being  dene 
the  edges  of  the  rubber  cloth  should  be  raised  so  as  to  direct  the 
fluid  into  the  tub  or  basin  at  the  side. 

When  the  tumor  is  very  vascular  and  great  bleeding  is  likely  to 
occur  in  emptying  the  contents,  the  pedicle  should  be  found  if  pos- 
sible and  compressed  with  catch-forceps. 

Adhesion  of  the  omentum  and  the  abdominal  and  pelvic  viscera 


OVARIOTOMY.  5(53 

is  treated  after  the  tumor  is  emptied  of  its  fluid  contents.  The 
omental  adhesions  are  most  easily  tied  while  attaclied  to  the  tumor, 
and  that  should  be  the  rule,  but  if  it  is  necessary  to  get  the  omen- 
tum out  of  the  way  before  the  operator  has  time  to  tie  it  properly, 
compression-forceps  may  be  put  on,  and  the  whole  wrapped  up  in  a 
carbolized  towel,  and  left  on  the  abdomen  at  the  upper  angle  of  the 
wound  until  tlie  cyst  is  removed,  when  attention  can  be  given  it. 
It  should  then  be  tied  in  sections  of  about  the  width  of  two  fin- 
gers. 

Dr.  Keith  treats  adhesions  to  the  bowels  and  mesentery  by  mak- 
ing traction  upon  the  cyst  and  pressing  against  the  adhesions  with  a 
sponge.  In  this  way  the  adherent  tissues  can  be  pushed  apart  with 
less  injury  than  in  any  other  way.  Pulling  upon  adhesions  should 
always  be  avoided,  if  possible.  Sometimes  when  there  are  many  ad- 
hesions high  up  strong  traction  must  be  made,  there  being  no  other 
way  of  separating  the  firm  adhesions,  but  it  is  a  dangerous  practice 
and  only  to  be  resorted  to  when  it  can  not  be  avoided.  Long  bands 
of  adhesions  should  be  tied  before  being  detached,  and  the  following 
points  should  be  observed  ;  to  have  no  tension  upon  these  parts  ;  to 
ligate  as  far  from  the  free  end  as  possible,  and  make  sure  that  all 
bleeding  is  stopped  before  letting  go  the  parts.  The  bleeding  which 
comes  from  the  broad  adherent  surfaces  which  have  been  separated, 
should  be  controlled  by  placing  sponges  in  the  abdomen  and  making 
pressure,  and  as  soon  as  possible  bleeding  points  should  be  looked 
for  and  the  vessels  ligated.  When  the  sponges  are  removed  the 
position  of  the  bleeding  vessels  can  be  seen.  When  there  are  many 
adhesions  high  up  in  the  abdomen,  it  is  an  advantage  to  find  the 
pedicle,  clamp  it  with  two  spring  catch-forceps,  and  divide  it,  and 
then  remove  the  tumor  from  the  pelvis  first.  When  the  adhesions 
are  all  treated  and  the  tumor  removed,  the  sponges  which  have  been 
introduced  should  be  removed,  and  the  bleeding  vessels  caught  up 
and  tied.  During  this  search  for  bleeding  vessels  in  the  pelvis  the 
assistant  holds  the  side  of  the  abdominal  wound  with  his  left  hand, 
and  with  a  concave  mirror  in  his  right  throws  light  into  the  pelvis. 
In  using  the  mirror  the  assistant  directs  it  so  that  he  himself  can  see, 
knowing  that  if  he  can  see  the  operator  will  see  also.  The  artificial 
light  is  to  be  used  as  little  as  possible,  because  if  once  begun  it  is 
difiicult  afterward  to  do  without  it. 

Drainage  should  be  employed  when  from  the  number  of  adhe- 
sions there  is  seen  to  be  a  free  transudation  of  serum  ;  when  all  the 
bleeding  has  not  been  or  can  not  be  stopped,  and  when  either  of  the 
above  conditions  are  present  even  in  a  very  limited  degree  and  the 


564  DISEASES  OF  WOMEN. 

patient  is  feeble.  The  tnl)e  sliould  be  left  in  until  tlie  discharge 
becomes  clear. 

When  adhesions  to  the  intestines  or  pelvic  organs  are  so  iinn 
and  extensive  that  they  can  not  be  separated  with  safety,  Dr.  T.  F. 
Miner,  of  Buffalo,  enucleates  the  tumor  or  cyst  from  its  peritoneal 
covering.  This  can  be  done,  but  it  is  often  exceedingly  difficult, 
and  there  is  left  a  large  surface  from  which  a  free  transudation 
takes  place,  and  requires  long-continued  drainage.  This  method  is 
not  practiced  much  now,  except  in  cases  of  intraligamentous  cyst. 

When  adhesions  are  very  extensive  and  firm  there  usually  has 
been  inflammation  of  the  cyst,  and  then  its  layers  can  not  be  sepa- 
rated ;  this  renders  enucleation  impossible. 

Treatment  by  Drainage  answers  in  such  cases  if  the  cyst  is  small 
or  of  medium  size.  If  the  cyst  is  adherent  to  the  abdominal  wall  it 
is  laid  open  without  being  separated  and  its  cavity  thoroughly 
cleaned  out,  and  a  drainage-tube  introduced,  and  kept  in  place.  The 
sac  is  washed  out  frequently,  and  when  it  has  contracted  down  it 
may  be  induced  to  close  by  the  use  of  tincture  of  iodine  and  car- 
bolic acid.  When  not  adherent  to  the  abdominal  wall,  but  so  gen- 
erally adherent  to  the  viscera  that  exploration  is  deemed  impossible, 
the  free  portion  of  the  sac  should  be  trimmed  off  and  its  edges  care- 
fully united  to  the  incision  in  the  abdominal  wall,  and  then  the 
drainage  practiced. 

1  am  aware  that  an  experienced  and  dexterous  operator  can  man- 
age very  bad  adhesions,  but  there  are  cases  where  it  is  safer  to  use 
drainage.  Five  cases  have  been  treated  in  this  way  in  my  own  prac- 
tice, and  four  of  them  recovered.  In  the  fifth,  a  bad  case  of  rupt- 
ured cyst  in  which  there  had  been  very  general  peritonitis,  the 
cyst  was  adherent  everywhere.  I  could  not  find  a  single  free  spot, 
and  the  patient  was  very  feeble.  The  sac  was  filled  with  inflamma- 
tory products,  winch  were  carefully  cleared  out,  and  large  drainage- 
tubes  used.  She  improved  for  a  time  and  took  food  better  than  she 
had  done  before,  but  died  at  the  end  of  a  week,  apparently  from 
uraamia ;  the  kidnevs  were  found  to  be  diseased. 

In  case  of  very  intimate  adhesions  to  the  liver,  spleen,  uterns, 
bladder,  or  intestines,  Dr.  W.  L.  Atlee  did  not  detach  them  at  all, 
but  separated  the  peritoneal  from  the  middle  coat  of  the  cyst  at  the 
point  of  attachment,  and  left  it  there.  This  also  is  not  often  neces- 
sary, but  it  may  be  the  easiest  and  safest  thing  to  do,  and  if  drain- 
age is  employed  good  results  may  be  expected.  In  this  I  have  had 
no  experience. 

Arrest  of  Haemorrhage. — All  adhesions  in  the  form  of  bands  ex- 


OVARIOTOMY.  565 

tending  from  the  cyst  to  other  parts  should  be  tied  before  dividing 
them.  This  applies  especially  to  adhesions  of  the  omentum. 
Large  bands  sliould  be  tied  with  prepared  silk  ligatures.  The  liner 
bands  may  be  tied  with  catgut.  In  my  own  practice  I  use  silk  alto- 
gether. Intimate  adhesions  which  have  to  be  separated  by  trac- 
tion leave  bleeding  surfaces,  and  if  any  large  vessels  are  found  they 
should  be  tied  if  possible.  General  oozing  can  usually  be  stopped 
by  pressure  with  a  sponge.  Hemorrhage  deep  down  in  the  pelvis 
from  vessels  large  enough  to  be  ligated  can  be  reached  by  throwing 
in  the  light  from  the  mirror  and  using  a  long  artery-forceps.  The 
ligature  can  be  easily  tied  by  using  the  counter-pressure  instrument 
employed  in  tying  the  sutures  in  the  operation  for  restoration  of  the 
cervix  uteri. 

To  check  oozing  from  surfaces  like  the  uterus,  liver,  or  spleen, 
pressure  with  sponges  is  to  be  performed  as  stated  already.  An 
application  of  persulphate  of  iron  is  made  by  some  operators,  and 
the  thermo-cautery  has  also  been  commended.  Both  are  objection- 
able, and  should  be  avoided  if  possible. 

After-Treatment. — The  bed  in  which  the  patient  is  placed  should 
be  warmed  to  about  the  normal  surface  temperature.  The  patient's 
head  sliould  be  covered  with  a  soft  woolen  shawl  or  soft  blanket. 
The  hands  should  be  kept  under  the  bed-covers  and  not  disturbed. 
The  pulse  should  be  watched  at  the  temporal  artery.  A  hot-water 
bag  may  be  placed  near  the  feet,  but  not  in  contact  with  them.  I 
have  repeatedly  seen  the  feet  burned  by  placing  a  hot-water  bag 
close  to  the  skin.  This  will  not  occur  when  the  bag  is  wrapped  in 
flannel.  The  air  in  the  room  should  be  kept  at  about  Y0°  F.,  and 
ventilation  secured  without  having  the  patient  in  a  draught.  For 
a  number  of  hours  ether  is  thrown  off  with  the  expired  air,  and  it 
is  difficult  to  keep  the  air  in  the  room  agreeable.  It  is  fortunate  if 
the  patient  sleeps  after  the  operation,  and  no  effort  should  be  made 
to  awaken  her,  as  is  frequently  done,  to  find  out  how  she  feels. 

During  the  first  twenty-four  hours  or  more,  the  greater  the 
amount  of  rest  that  can  be  obtained  the  better.  Absolutely  noth- 
ing should  be  given  in  the  way  of  food  or  medicine  unless  there  is 
some  urgent  demand  for  either.  ISTausea  and  vomiting,  which  occa- 
sionally occur,  should  be  counteracted  with  sips  of  hot  water  if  the 
patient  is  anxious  to  have  something  to  di'ink — not  otherwise. 

Keith  usually  gives  a  hypodermic  dose  of  morphine  immediately 
after  the  operation,  to  control  the  restlessness  which  supervenes 
when  the  patients  come  out  of  the  anaesthetic.  This  is  not  always 
necessary.     I  wait  and  see  if  there  is  much  restlessness  or  pain,  and 


566  DISEASES  OF  WOMEN. 

if  there  is,  the  hypodermic  is  given.  Nervous  restlessness  alone  can 
often  be  controlled  by  the  efforts  of  a  judicious,  experienced  nurse. 
If  the  patient  can  be  controlled  until  night,  it  is  better  to  withhold 
the  morphine  until  then. 

This  expectant  treatment  should  be  continued  until  the  stomach 
has  become  reliable  and  gas  has  passed  from  the  bowels.  In  many 
cases  nothing  else  is  required  during  the  first  forty-eight  hours.  I 
am  sure  that  great  harm  is  done  by  giving  nourishment  and  medi- 
cines when  there  is  no  demand  for  either.  I  certainly  have  seen 
more  harm  come  from  doing  too  much  at  first  than  from  doing  too 
little.  There  are  exceptions  to  this  rule  of  doing  nothing.  In  case 
the  vomiting  continues,  and  is  not  relieved  by  hot  water,  I  use  the 
following :  Magnesise  carb.,  3  ij  ;  magnesise  sulph.,  3  iij  ;  aquse  menth. 
I^ip.,  §  iij.  Of  this,  a  teaspoonful  may  be  given  every  one,  two,  or 
three  hours  in  a  dessertspoonful  of  water.  This  prescription  is  used 
in  the  Samaritan  Hospital  in  London.  A  mustard  plaster  to  the  pit 
of  the  stomach  is  also  usefid. 

When  these  remedies  fail,  and  the  patient  complains  of  burning 
in  the  stomach,  dessertspoonful  doses  of  iced  water  may  be  used. 
When  the  patient  is  depressed,  ten  drops  of  whisky  in  a  teaspoonful 
of  water  every  few  minutes  will  be  of  service.  In  desperate  cases  I 
have  given  a  large  quantity,  as  much  as  the  patient  could  drink,  of 
lukewarm  water  and  a  little  taljlc  salt.  This  is  thrown  oif  prom])tly, 
and  sometimes  gives  relief.  It  should  not  be  repeated.  If  relief  is 
obtained  and  the  nausea  returns,  the  stomach  should  be  washed  out 
in  the  usual  way. 

When  the  vomiting  is  attended  with  abdominal  pain,  morphine 
hypodennically  will  give  relief  in  many  cases. 

Peritonitis  and  Septicaemia  after  Laparotomy. — From  recent  re- 
ports in  the  literature  of  medicine  it  appears  that  a  new  departure 
has  been  taken  in  the  after-treatment  of  cases  of  ovariotomy  and 
similar  opei'ations.  In  place  of  giving  opium  and  keeping  the 
bowels  at  rest  for  several  days,  the  bowels  are  moved  early,  and 
opium  is  withheld.  Cases  which  show  signs  of  septicaemia  or  peri- 
tonitis are  given  saline  cathartics.  It  is  claimed  that  free  action  of 
the  bowels  effects  a  kind  of  drainage  which  arrests  the  tendency  to 
inflammation  of  the  peritontienm.  and  also  favors  the  elimination  of 
septic  material.  One  should  gladly  accept  whatever  theories  or  facts 
may  be  advanced  in  favor  of  this  plan  of  treatment,  or  any  other 
which  might  prove  better  than  the  old  ways  of  managing  such  cases. 
But  I  have  failed  to  see  that  this  new  treatment  has  many  advantages. 

So  far  as  I  can  learn,  the  results,  on  the  whole,  do  not  compare 


OVARIOTOMY.  56Y 

well  with  those  of  other  surgeons  who  give  opium  and  let  rhe  Ixjwels 
and  the  stoniacli  rest,  until  the  first  dangers  are  past.  Furthermore, 
I  have  found  in  my  own  practice  that  as  soon  as  the  indications  for 
cathartics  appear,  it  is  impossible  to  have  the  patient  retain  tliem,  in 
the  great  majority  of  cases. 

Perhaps  the  advocates  of  this  treatment  may  be  able  to  anticipate 
the  coming  storm,  and,  by  giving  salines,  ward  it  oif ;  but  I  have  not 
been  able  to  do  so. 

"While  there  are  a  number  of  reasons  why  opium  should  be  used, 
I  have  not  yet  heard  of  any  good  reason  why  it  should  not  be,  in 
certain  cases. 

That  there  are  patients  who  do  not  need  opium,  and  others  with 
whom,  it  does  not  agree,  must  be  admitted ;  but  the  majority  require 
it  to  relieve  pain,  produce  sleep,  and,  above  all,  rest  and  quiet,  which 
are  so  very  necessary  to  recovery  after  major  operations.  These 
effects  of  opium,  it  may  be  claimed,  simply  contribute  to  the  comfort 
of  the  patient^  but  do  not  secure  safety  or  aid  in  recovery.  Grant- 
ing that  such  may  be  the  case,  the  humane  surgeon  will  find  in  this 
good  reason  for  the  use  of  opium ;  but  I  am  confident  that  opium 
has  a  therapeutic  value  in  addition  to  that  of  relieving  suffering. 

The  danger  from  shock  which  arises  from  major  operations  is,  I 
am  sure,  controlled  by  opium  better  than  by  any  other  drug.  So 
also  is  the  depression  from  anaemia  resulting  from  haemorrhage. 
All  careful  observers  have  noticed  that  the  rapid  and  feeble  pulse 
becomes  fuller,  slower,  and  steadier  under  the  influence  of  opium. 
The  anxious,  pinched  face  also  changes  to  a  better  expression.  This 
has  led  me  to  look  upon  opium  as  the  most  reliable  of  all  heart  ton- 
ics in  the  depression  which  follows  these  operations.  When  the 
organic  nervous  system  is  tottering  under  the  oppression  of  severe 
injuries  to  the  abdominal  and  pelvic  viscera,  opium  is  the  greatest 
sustaining  agent.  Alcohol,  no  doubt,  will  bridge  over  a  moment  of 
extreme  and  immediate  danger,  but  its  effects  must  almost  always 
be  supplemented  with  opium  in  order  to  obtain  a  continuous  sus- 
taining effect. 

Perhaps  more  important  still  is  the  question,  Does  opium  have 
the  power  of  preventing  peritonitis  and  septicaemia,  or  of  controlling 
their  fatal  tendencies  ?  To  judge  fairly  of  the  therapeutic  effects  of 
opium  in  surgery,  it  is  necessary  to  keep  in  mind  the  fact  that  after 
an  operation  there  are  injured  tissues  left  that  must  be  repaired. 
These  tissues  may  or  may  not  be  affected  with  septic  material,  but 
in  either  case  the  safety  of  the  patient  depends  upon  these  wounded 
tissues  being  speedily  closed  in  by  reparative  material,  which  re- 


568  .  DISEASES   OF  WOMEN. 

stores  continuity  of  tissne  and  at  the  same  time  protects  the  normal 
surrounding  tissue  from  inflammation  and  the  jmtient  from  general 
septicaemia.  Now  this  process,  by  which  the  general  system  is  pro- 
tected from  the  dangerous  effects  of  local  injuries,  requires  time ; 
and  it  is  the  most  important  time,  because  upon  completion  of  this 
protection  depends  the  safety  of  the  patient  to  a  great  extent. 
Wounds  may  do  badly,  but,  if  an  exudation  has  been  thrown  around 
them  which  protects  from  septicaemia,  recovery  may  be  expected 
Of  course,  the  modern  surgeon  protects  his  cases  from  sepsis  l)y  his 
cleanly  operating ;  but  in  spite  of  his  best  efforts  there  may  be 
trouble  occasionally,  and  then  the  great  point  is  to  gain  time  for 
this  natural  protective  process,  which  comes,  or  should  come,  first 
in  the  order  of  restoration.  The  princii)al  condition  necessary  to 
secure  the  protective  factor  in  the  general  process  of  repair  is  re- 
pose or  quietude  of  the  nervous  and  circulatory  sj^stems,  and  ojjium 
is  the  most  potential  agent  in  effecting  this  condition.  The  process 
of  repair  is  arrested  when  the  nervous  system  is  in  turmoil  and  the 
circulation  is  running  wild,  and  opium  should  be  used  to  give  the 
necessary  rest.  It  is  a  fatal  mistake  to  wait  until  there  is  evidence 
of  inflammation  or  septicaemia.  It  should  be  given  to  control  the 
nervous  excitation  which  generally  precedes  these  complications. 

The  time  to  give  it,  then,  is  an  important  question.  Some  of 
the  most  successful  surgeons  give  it  immediately  after  the  ojieration, 
and  that  is  best  when  the  case  is  bad  and  there  is  shock.  In  easy 
cases  I  prefer  to  wait  until  the  ether  effects  pass  off  to  some  extent ; 
and  if  there  is  distress  or  pain  present,  then  is  the  time  to  give 
opium,  and  the  effect  should  be  kept  up  until  there  is  no  danger  of 
complications,  so  far  as  the  condition  of  the  i:)atient  indicates. 

The  way  of  giving  it  is  of  some  importance,  no  doubt.  I  prefer 
to  give  it  at  first  hypodermically,  and  keep  up  the  effect  in  that 
way,  or  by  rectal  instillations  of  opium  and  warm  water. 

The  question  which  follows  is,  When  shall  the  opium  be  with- 
drawn, and  cathartics  resorted  to  ?  Opium  should  be  gradually 
given  up  as  the  constitutional  and  local  evidences  of  disease  sub- 
side, and  then  cathartics  or  laxatives  should  be  given.  To  state 
this  in  another  way:  opium  should  only  l)e  given  when  there  are 
indications  for  its  use,  and  it  should  be  given  up  as  soon  as  the  indi- 
cations disappear.  The  bowels  should  rest  until  the  time  for  peri- 
tonitis is  past,  or,  if  there  has  been  inflammation  or  sepsis,  when  the 
acute  symptoms  and  signs  of  these  have  subsided. 


CHAPTER   XXX. 

ILLUSTEATIVE   CASES    OF   OVAEIAN   NEOPLASMS. 

In  giving  the  Mstories  of  ovarian  neoplasms  it  has  been  deemed 
best  to  omit  simple  and  typical  cases,  because  they  would  add  noth- 
ing to  the  description  already  given.  The  following  complicated 
ones,  on  the  other  hand,  will  tend  to  convey  clearer  ideas  of  the 
peculiar  cases  which  are  frequently  met  in  practice,  and  the  aj^proved 
methods  of  management  adopted  at  the  present  time. 

Monocyst  of  the  Right  Ovary ;  Firm  Adhesions  to  the  Abdominal 
Wall ;  Necrosis  of  the  Posterior  Wall  of  the  Cyst ;  Ovariotomy ;  Re- 
covery.— The  patient  was  fifty  four  years  old,  and  the  mother  of  four 
children.  After  the  birth  of  her  last  child,  the  attending  physician 
told  her  that  she  had  a  small  tumor  on  the  right  side  of  the  uterus. 
There  was  considerable  intermittent  pain  in  the  region  of  the  neo- 
plasm from  the  time  that  it  was  fiist  discovered  up  to  the  time  that 
she  came  under  the  care  of  my  associate,  Dr.  Palmer,  fom*  years 
afterward.  The  growth  of  the  tumor  was  slow,  scarcely  noticeable 
for  the  first  three  years,  but  very  noticeable  during  the  last  year. 

When  she  first  came  under  the  care  of  Dr.  Palmer  the  tumor  ex- 
tended above  the  umbilicus,  and  fluctuation  was  well  marked. 
There  was  evidence  of  circumscribed  peritonitis,  and,  although  the 
tumor  was  movable,  adhesions  were  being  formed.  The  peritonitis 
was  quite  pronounced  at  this  time,  and  the  constitutional  symptoms 
were  well  defined.  She  was  treated  for  this,  and  in  about  two  weeks 
the  acute  symptoms  subsided,  but  she  still  remained  weak.  The 
doctor  sent  her  home  in  the  hope  that  she  would  gain  strength,  and 
the  tumor  being  still  small  there  was  no  urgent  necessity  for  its  re- 
moval. In  a  month  she  returned  to  the  hospital  not  improved. 
She  was  losing  flesh,  the  parts  were  still  tender,  the  appetite  poor, 
the  pulse  weak,  and  the  temperature  kept  above  100°  F. 

Another  effort  vr as  made  to  get  her  into  better  general  condition, 
but  without  success.     She  lost  strength  gradually,  and  i^  was  de- 

569 


570  DISEASES  OF  WOMEN. 

cided  that  tlie  only  chance  for  her  was  by  retooving  the  tumor.  At 
this  time  the  adhesions  were  firm  and  involved  all  parts  of  the  ab- 
dominal wall  which  were  in  contact  with  the  tumor. 

Just  before  the  operation  the  j)ulse  was  120  and  the  temperature 
101°.  When  the  abdominal  incision  was  made,  the  adhesions  were 
very  firm  and  vascular,  except  in  a  small  space  just  above  the  sym- 
phisis pnbis.  The  cyst  was  emptied  by  tapping,  and  the  lower  por- 
tion, which  was  not  adherent,  was  drawn  out,  and  the  pedicle  grasped 
with  strong  fixation  forceps,  and  divided.  The  adhesions  were  now 
easily  reached  and  separated.  The  pedicle  was  then  ligated,  and  the 
bleeding  stopped  by  pressure  with  sponges.  By  managing  the  pedi- 
cle in  this  way,  the  tendency  to  bleeding  from  the  site  of  adhesions 
was  lessened  very  decidedly.  When  all  bleeding  had  stopped  the 
wound  was  closed  and  dressed  in  the  usual  way. 

An  examination  of  the  cyst  showed  a  portion  of  its  posterior 
wall  (al)out  the  size  of  one's  hand)  perfectly  bloodless,  of  a  dirty 
gray  color  and  friable,  indicating  that  it  was  necrosed.  No  doubt 
the  death  of  this  portion  of  the  sac  had  taken  place  many  days  be- 
fore the  operation,  and  I  presume  was  the  cause  of  the  constitutional 
disturbance. 

Fro:n  the  facts  in  this  case  and  from  those  observed  in  other  cases 
of  necrosis  of  the  cyst-wall,  I  believe  that  the  dead  tissue  causes  a 
form  of  septicaemia,  certainly  in  this  case  there  was  nothing  else 
found  to  cause  the  high  temperature  and  pulse,  and  the  subsequent 
history  confirms  this  view. 

The  operation  was  performed  between  eleven  and  twelve  o'clock. 
She  soon  recovered  from  the  ether,  and  showed  no  depression.  At 
seven  in  the  evening  her  condition  was  better  than  before  the  oper- 
ation. The  pulse  was  112,  temperature  99"5°  F.  and  respiration  20. 
During  the  night  she  had  slight  pain  in  the  abdomen  and  was  given 
a  hypodermic  injection  of  morphine.  She  slept  well,  and  had 
no  vomiting.  On  the  second  day  there  was  some  slight  distention 
of  the  abdomen  from  gas ;  this  was  relieved  by  six  grains  of  sul- 
phate of  quinia  in  solution,  given  by  the  rectum. 

From  this  time  onward  her  progress  was  very  satisfactory.  The 
temperature  never  rose  above  99°  F.  Five  days  after  the  opei-a- 
tion  the  bowels  were  moved  by  enema.  On  the  twelfth  day  she 
left  her  bed,  and  four  days  later  was  able  to  walk  about  the  ward. 
About  four  weeks  after  the  operation  the  left  leg  became  swollen, 
and  remained  so  for  about  a  week.  The  cause  of  this  was  not 
certain. 

She  was  discharged  from  the  hospital  at  the  end  of  the  fifth 


ILLUSTRATIVE  CASES  OF  OVARIAN  NEOPLASMS.  5^1 

week  feeling  perfectly  well  and  having  gained  flesli  and  strength 
8ur()risinglj. 

Intraligamentous  Ovarian  Cystoma;  Multiple  Cyst  of  the  other 
Ovary;  Ovariotomy  and  Hysterectomy;  Recovery. — This  patient  was 
under  the  care  of  mj  friend  Dr.  F,  H.  Stuart,  and  most  of  the 
facts  in  the  history  of  the  case — before  and  after  the  operation — are 
given  here  as  I  obtained  them  from  him. 

The  lady  was  iifty-six  years  of  age,  and  had  passed  the  meno- 
pause about  six  years.  At  the  age  of  thirty-nine  years  she  had 
a  pelvic  abscess  which  opened  into  the  bladder,  and  she  was 
then  sick  for  a  long  time.  About  three  years  before  the  time 
when  this  history  was  taken  she  noticed  a  tumor  in  the  right  iliac 
region. 

She  was  first  seen  by  Dr.  Stuart,  April  30,  1886.  He  found 
the  uterus  high  up  behind  the  symphysis,  attached  to  an  elastic 
tumor,  which  was  immovable,  and  by  external  examination  appeared 
to  be  larger  than  a  fetal  head  and  extending  up  into  the  right  iliac 
fossa.  There  were  two  other  tumors  of  smaller  size,  one  above 
and  one  to  the  left  of  the  larger  one.  These  appeared  to  be  adher- 
ent to  the  first  one,  and  were  also  rather  immovable.  1  saw  the 
patient  the  next  day  with  the  doctor,  and  confirmed  the  diagnosis  of 
ovarian  cysts.  On  account  of  the  adhesions,  and  as  the  patient  was 
not  suffering  any  great  inconvenience,  we  thought  it  best  to  await 
further  developments. 

She  passed  a  very  comfortable  summer,  but  increased  steadily  in 
size,  with  a  corresponding  increasing  discomfort  in  locomotion. 
About  the  1st  of  December,  1886,  she  began  to  have  frequent  and 
painful  urination,  and  some  fever.  After  a  few  days  of  quiet  and 
some  quinine  (as  there  was  a  decided  intermittence  in  the  irritability 
of  the  bladder),  she  became  again  quite  comfortable. 

Immediately  before  the  operation  the  physical  signs  were  as  fol- 
lows :  The  general  outlines  of  the  enlarged  abdomen  were  irregular, 
three  cysts  could  be  mapped  out,  and  fluctuation  was  distinct  in 
each.  The  most  dependent  cyst  was  about  the  size  of  the  uterus  at 
the  seventh  month  of  utero-gestation,  and  occupied  the  center  and 
lower  region  of  the  abdomen.  It  was  not  movable  to  any  extent, 
and  appeared  to  be  separated  from  the  other  cysts  except  at  the  up- 
per and  right  side,  where  it  seemed  to  be  adherent  but  not  firmly 
so.  The  two  other  cysts  occupied  the  upper  and  left  lower  regions 
of  the  abdomen,  raising  the  diaphragm  and  causing  the  lower  ribs  to 
project  slightly.  These  two  cysts  could  be  moved  together  in  the 
abdomen,  but  were  closely  united  forming  one  tumor.     The  flnetua- 


572  DISEASES   OF   WOMEN. 

tion  was  very  clear  in  each  of  them,  but  was  not  distinctly  felt  through 
the  mass  formed  by  the  two. 

All  around  the  circumference  of  the  abdomen  there  was  dull- 
ness on  percussion,  and  distinct  fluctuation,  though  broken  at  points 
where  the  divisions  between  the  cysts  were.  These  signs  simply  in- 
dicated the  presence  of  a  multiple  cystic  tumor.  The  umbilicus 
was  high  up,  showing  that  the  lower  portion  of  the  abdominal  mus- 
cles was  distended  most,  and  in  a  space  about  five  inches  in  diame- 
ter in  the  umbilical  region  there  was  tympanitic  resonance  and 
gurgling  on  pressure,  showing  the  presence  of  intestines  at  that 
point.  Taken  altogether  the  abdomen  appeared  to  be  occupied  by 
a  large  cystic  tumor  with  a  mass  of  intestines  in  a  cup-shaped  space 
in  its  center. 

By  vaginal  touch  the  uterus  was  found  displaced  upw^ard  and 
forward,  and  the  cervix  could  be  reached  without  difliculty,  owing 
to  its  being  crowded  toward  the  pubes.  Behind  the  uterus  and  ex- 
tending down  into  the  upper  and  posterior  portion  of  the  pelvis  a 
segment  of  cyst  was  found.  The  uterus  was  displaced  by  moving 
the  cyst  in  front,  and  pushed  forward  by  raising  the  cyst  behir.d  it. 
The  examination  indicated  very  certainly  tliat  there  was  a  cystic  ova- 
rian tumor  of  the  multiple  variety,  but  there  was  evidently  more 
than  that.  The  fact  that  the  uterus  was  involved  raised  the  ques- 
tion of  uterine  iibro-cyst,  as  well  as  ovai-ian  tumor,  but  there  was 
some  doubt  about  the  nature  of  the  whole  mass.  It  was  possible 
that  the  uterus  was  simply  adherent  to  the  cystic  tumor,  and  that 
the  adhesions  had  been  formed  while  the  tumor  was  still  in  the  pel- 
vis, and  the  uterus  had  been  carried  upward  as  the  tumor  grew.  It 
also  was  presumed  that  there  might  be  two  cystic  tumors,  and  that 
the  uterus  was  attached  to  one  of  these. 

While  the  exact  pathological  conditions  were  not  decided  upon, 
two  facts  Mere  (piite  evident ;  first,  that  there  was  at  least  an  ovarian 
tumor,  and  tliat  the  patient  must  obtain  relief,  if  at  all,  by  ovariot- 
omy. 

Operation. — After  making  the  abdominal  incision,  the  flrst  cyst 
\vas  exposed,  and  adhesions  of  the  omentum  were  found  on  the  right 
side.  The  omentum  was  vascular  and  its  adhesions  covered  the 
upper  part  of  the  tumor.  After  emptying  the  cyst  by  tapping,  the 
omental  adliesions  were  ligated  and  separated,  and  it  was  tlien  found 
that  this  cyst  had  no  connection  with  the  cysts  above,  but  was  situated 
between  the  folds  of  the  broad  ligaments,  and  extended  from  one 
side  of  the  pelvis  to  the  other,  between  the  uterus  and  the  bladder. 
The  uterus,  being  behind  the  cyst-wall  and  firmly  attached  to  it,  had 


ILLUSTRATIVE  CASES  OF  OVARIAN  NEOPLASMS.  6Y3 

been  stretelied  laterally  so  that  its  long  diameter  was  transverse. 
The  empty  cyst  was  held  outside  of  the  abdominal  womid  at  this 
stage  of  tlie  operation  by  forceps,  and  the  incision  extended  uj^ward 
so  that  I  could  reach  the  other  tumor,  which  I  found  to  be  a  multi- 
ple cyst  of  the  left  ovary. 

The  four  lar,<j:est  cysts  were  tapped  separately,  first  the  one  on 
the  right  side,  and  next  the  one  above  and  to  the  left,  then  the  one 
that  dij)ped  down  behind  the  cyst  of  the  broad  ligament  and  uterus, 
and  lastly  a  middle  one  between  the  upper  and  lower  cysts.  There 
was  a  deep  fissure  between  the  two  cysts  on  the  left  side  through 
which  the  intestines  found  their  way  up  to  the  abdominal  wall, 
which  accounted  for  the  tympanitic  resonance  obtained  during  the 
examination.  This  tumor  had  an  ordinary  pedicle  starting  from  the 
left  posterior  surface  of  the  broad  ligament,  which  was  ligated  with 
silk,  and  the  tumor  removed. 

Having  disposed  of  this  tumor,  I  returned  to  the  cyst  of  the 
broad  ligaments,  and  upon  laying  it  open  and  inspecting  its  cavity,  I 
found  at  the  bottom  of  it  a  papillomatous  mass  which  had  the  ap- 
pearance of  an  epithelioma. 

I  then  undertook  to  enucleate  this  cyst,  the  lower  portion  of 
which  was  fixed  in  the  broad  hgaments,  between  the  bladder  and 
uterus,  as  already  stated,  but  the  adhesions  were  so  firm  and  the 
vascularity  so  great,  that  this  was  impossible.  I  then  tried  to  enu- 
cleate the  inner  wall  of  the  cyst,  but  this  was  also  impracticable. 
The  thought  occurred  to  me  that  I  might  stitch  the  cyst-walls  to  the 
sides  of  the  incision  in  the  abdominal  walls,  but  as  the  cyst  dipped 
down  into  the  broad  ligaments  on  both  sides,  two  pockets  would 
have  been  left,  which  would  have  been  difficult  to  drain.  The 
papillomatous  mass  in  the  central  part  of  the  sac  would  have  been 
left  also,  and  that,  I  presumed,  would  have  interfered  with  the  clos- 
ure of  the  sac.  and  the  final  recovery  of  the  patient. 

It  seemed  as  if  the  whole  thing  should  be  removed,  but  I  could 
not  take  in  all  the  tissue  involved  in  any  ordinary  clamp. 

I  then  tied  and  divided  the  broad  ligament  on  both  sides  from 
the  outside  toward  the  center,  so  as  to  form  a  pedicle  which  could 
be  grasped  in  the  clamp.  The  bladder  was  dissected  from  the  cyst- 
wall  far  enough  to  let  the  clamp  get  down  below  the  uterus  and  the 
most  dependent  portion  of  the  sac.  Keith's  modification  of  Baker 
Brown's  clamp  was  then  applied,  and  the  cyst  and  uterus  removed. 

A  drainage-tube  was  introduced  above  the  clamp,  and  the  abdom- 
inal wound  closed  from  above  downward. 

The  operation  was  completed  at  noon,  and  five  minims  of  Ma- 


574  DISEASES   OF   WOMEN. 

gendie^s  solution  of  morphine  were  given  hvpodermieally  at  once. 
She  slept  quietly  for  about  two  hours  and  then  had  some  nausea,  and 
vomited  a  mouthful  of  mucus.  The  remainder  of  the  day  was  passed 
comfortably,  the  catheter  was  used,  and  sips  of  hot  water  were  given. 
At  midnight  the  temperature  was  99f  °  and  pulse  86.  The  second 
day  was  without  much  to  note  except  that  the  temperatm-e  went  up 
to  101 1°  but,  toward  midnight,  it  came  down  to  100°  and  the  pulse 
was  80.  There  was  some  distention  of  the  bowels  which  was  relieved 
by  quinine,  given  by  the  rectum.  From  this  onward  the  patient 
did  very  well,  the  pulse  was  good  and  temperature  ranged  from  99° 
to  100°.  She  required  morphine  to  keep  her  comfortable,  but  noth- 
ing more. 

After  the  operation  the  kidneys  acted  very  well,  the  catheter  be- 
ing used  for  two  days,  and  after  that  the  patient  urinated  without 
trouble  and  passed  the  usual  quantity  of  water.  On  the  tenth  day, 
while  urinating,  the  dressing  of  the  wound  became  saturated  with 
urine,  showing  that  the  upper  part  of  the  bladder  had  opened ;  the 
dressings  were  removed,  but  the  opening  was  covered  by  the  clamp 
and  could  not  be  seen.  Several  times  afterward  when  she  urinated 
she  passed  a  very  small  quantity  of  water  by  the  urethra,  the  larger 
portion  passing  by  the  side  of  the  clamp.  Between  the  times  M'hen 
she  urinated  there  was  no  leaking  from  the  opening  in  the  bladder. 
She  was  not  permitted  to  urinate  after  this ;  the  catheter  being  used 
at  regular  intervals. 

For  two  days  very  little  urine  escaped  from  the  opening,  and 
then  a  little  began  to  come,  which  made  the  wound  unclean. 

It  being  quite  evident  that  the  stump,  below  the  clamp,  had  un- 
dergone necrosis  to  a  considerable  extent,  an  elastic  ligature  was 
passed  around  the  stump,  below  the  clamp,  in  the  hope  that  it  would 
cut  its  way  through  the  softened  and  dead  tissues,  and  set  the 
clamp  at  liberty  ;  it  did  so  to  a  limited  extent  only,  and,  as  it  was 
very  difficult  to  keep  the  wound  clean,  the  clamp,  on  the  fifteenth  day 
after  the  operation,  was  carefully  liberated  by  dividing  the  dead  tissues 
of  the  stump  with  the  knife  and  scissors.    No  haBmorrhage  was  caused. 

When  the  clamp  was  removed,  it  was  found  that  the  necrosis  of 
the  tissue  extended  farthest  on  the  right  side,  and  it  was  at  this  point 
where  the  bladder  was  open.  At  first  it  was  thought  that  the  blad- 
der had  been  included  in  the  clamp ;  but  that  did  not  seem  possible, 
because  of  the  extreme  care  taken  to  avoid  it  when  applying  the 
clamp,  and  also  from  the  entire  absence  of  all  functional  disturb- 
ance of  the  bladder  during  the  ten  days  immediately  succeeding  the 
operation. 


ILLUSTRATIVE   CASES  OP  OVARIAN  NEOPLASMS.  575 

After  removing  the  clamp,  and  seeing  how  far  the  death  of  the 
tissues  of  the  stumj3  liad  extended  on  the  right  side,  it  appeared  that 
the  opening  of  the  bladder  was  due  to  this  destruction  of  the  tissues. 
The  opening  occurred  on  the  right  (as  has  been  already  stated),  at 
the  site  of  the  old  cellulitis,  which  she  had  years  ago,  and  where  the 
abscess  discharged  into  the  bladder,  in  all  probability,  and  this  may 
account  for  the  death  of  the  tissue  below  the  clamp. 

During  the  operation  it  was  noticed  that  the  right  broad  liga- 
ment was  thickened  greatly,  and  changed  in  appearance,  owing  no 
doubt  to  the  products  of  the  old  inflammation,  and  the  damaged  state 
of  the  tissue  probably  favored  the  necrosis ;  this  may  have  been 
also  favored  by  the  pressure  of  the  abdominal  wall.  The  pedicle 
was  broad,  so  that  it  stretched  the  wound,  and  the  pressure  of  the 
strongly  retracted  edges  of  the  wound  may  have  helped  to  strangu- 
late the  right  side  of  the  stump,  the  vitality  of  which  was  of  a  low 
order. 

The  dressing  of  the  stump  and  abdominal  wound  now  became  a 
rather  difficult  task,  owing  to  the  escape  of  urine.  Iodoform  and 
absorbent  cotton  did  best  of  all.  Although  the  catheter  was  used, 
there  still  was  some  leaking  above.  The  urethra  became  tender  to 
the  passing  of  the  catheter,  and  then  the  doctor  tried  keeping  it  in 
the  bladder  continuously.  This  did  well  for  a  time,  but  had  to  be 
given  up  because  of  the  pain  caused.  By  the  free  use  of  cocaine 
the  catheter  could  be  used,  so  that  the  leaking  in  the  wound  was  not 
great.  During  all  this  time  her  general  condition  was  fairly  good, 
but  the  wound  healed  slowly,  and  she  needed  morphine  to  keep 
her  comfortable. 

About  this  time  several  of  the  ligatures  used  in  tying  the  broad 
ligament  on  the  right  side  came  slwslj  through  the  wound.  About 
five  weeks  after  the  operation,  and  while  she  was  apparently  Avell, 
except  that  the  fistulous  opening  of  the  bladder  remained  and  her 
strength  had  not  returned  fully,  she  was  taken  quite  ill ;  the  tem- 
perature ran  up  to  103°,  and  the  bowels  became  constipated ;  the 
appetite  was  entirely  lost,  and  she  looked  badly  in  the  face,  and  lost 
flesh  rapidly. 

There  was  a  hard,  irregular  mass  felt  in  the  rigbt  side  of  the 
abdomen  at  this  time,  which  was  presumed  to  be  a  local  inflamma- 
tion due  to  the  ligatures  used  in  ligating  the  omentum.  The  doctor 
and  I  were  not  without  some  fears  that  it  might  be  the  beginning 
of  some  malignant  disease,  but  it  proved  not  to  be  so.  Quinine 
given  by  inunction  and  the  rectum  controlled  the  fever  after  a  time, 
and  then  the  stomach  and  bowels  began  to  act  again. 


57C)  DISEASES   OF  WOME^. 

From  this  time  her  progress  was  favorable,  and  she  is  now  (one 
year  after  the  operation)  perfec'ly  well. 

A  Papillomatous  Moaocyst  of  the  Ovary.  Ovariotomy„  Fatal 
Termination  from  Haemorrhage. — The  patient  was  thirty-live  years 
old,  She  had  had  two  children.  For  about  one  jear  before  the 
ovarian  tumor  was  detected  she  suffered  from  menorrhagia.  When 
I  iirst  saw  her  she  was  quite  anaemic  from  long-continued  and  pro- 
fuse menstruation,  caused  by  polypoid  fungosities  of  the  uterine 
mucosa.  She  was  promptly  relieved  by  curetting.  At  that  time 
the  ovarian  cyst  was  about  the  size  of  a  pregnant  uterus  at  four  and 
a  half  months.  The  cyst  increased  in  size  rather  slowly.  She  had 
two  attacks  of  circumscribed  peritonitis,  one  at  the  upper  part  of 
the  cyst,  which  gave  rise  to  adhesions  to  the  abdominal  wall  above 
and  to  the  left  of  the  umbilicus.  About  eight  months  from  the 
time  that  I  iirst  saw  her,  and  after  the  slight  attacks  of  peritonitis, 
she  was  attacked  with  severe  pain  in  the  region  of  the  cyst,  but  there 
was  no  evidence  of  inflammation. 

At  this  time  the  cyst  became  very  tense,  and  there  was  general 
tenderness  and  heavy  pressure.  These  symptoms  subsided  for  a 
time,  but  there  were  several  attacks  of  this  kind,  each  one  being 
marked  by  a  sudden  increase  in  the  tension  of  the  cyst.  The  patient 
continued  to  be  rather  antemic,  there  were  wandering,  ill-defined 
pains  in  the  abdomen,  and  the  general  condition  showed  that  she  suf- 
fered more  than  is  usual  in  cases  of  uncomplicated  ovarian  cystoma. 

This  led  to  the  determination  to  operate,  though  the  size  of  the 
cyst  did  not  demand  immediate  interference. 

When  the  wall  of  the  abdomen  was  opened,  and  the  cyst  exposed, 
it  was  darker  in  color  than  it  should  be ;  adhesions  were  found  at 
the  upper  and  left  side,  and  also  low  down  and  near  the  median  line. 
Tapping  was  tried,  but  the  contents  of  the  cyst  would  not  flow.  The 
sac  was  then  opened,  and  its  contents  were  found  to  be  blood  and 
old  blood-clots  with  very  little  ordinary  ovarian  flui(i.  It  was  neces- 
sary to  pass  the  hand  into  the  cyst  to  evacuate  its  contents ;  this 
caused  fresh  and  profuse  bleeding.  The  patient  showed  the  loss  of 
blood  very  rapidl}'^ ;  great  haste  was  made  to  separate  the  adhesions, 
which  were  very  vascular  and  required  ligating. 

The  depression  became  more  and  more  marked,  and  it  looked  as 
if  the  patient  would  die  on  the  table.  The  cyst  was  hurriedly  re- 
moved, and  the  abdominal  wall  was  closed.  There  was  some  oozing 
from  the  adhesions,  and,  a.s  there  was  little  time  for  sponging  the 
peritoneal  cavity  and  stopping  the  bleeding,  which  was  only  a  very 
little  oozing,  a  drainage-tube  was  used.     The  patient  rallied  a  little, 


ILLUSTRATIVE   CASES   OF  OVARIAN  NEOPLASMS.  577 

and  there  were  hopes  that  she  might  be  saved.  There  was  consid- 
erable discharge  of  bloody  serum  from  the  tube,  which,  in  place  of 
becoming  less,  as  1  expected  it  would,  increased.  Whenever  the 
pulse  improved,  and  the  patient  gained  a  little  strength,  the  bleed- 
ing increased.  It  was  never  free  enough  to  warrant  my  opening 
the  abdomen  to  stop  it,  but  kept  on  just  enough  to  keep  the  patient 
down.  At  the  end  of  the  third  day  there  was  very  little  bleeding, 
and  thei'e  was  a  promise  of  success,  but  then  she  began  to  show  signs 
of  heart-clot,  and  she  died  on  the  fourth  day. 

The  inside  of  the  cyst  was  lined  with  a  layer  of  papillomatous 
material,  which  presented  a  cauliflower  appearance  not  unlike  that 
of  epithelioma  of  the  cervix  uteri. 

The  points  of  greatest  interest  in  the  history  of  this  case  are  the 
frequent  haemorrhages  which  took  place  in  the  cyst  during  its  growth 
and  the  unsatisfactory  character  of  the  operation  which  permitted 
the  loss  of  so  much  blood.  There  is  no  doubt  in  my  mind  but  that 
the  attacks  of  distress  and  extreme  and  sudden  distention  of  the  sac 
were  due  to  the  haemorrhages  in  the  cyst.  This  view  of  the  matter 
was  confirmed  by  the  large  number  of  blood-clots  which  were  found 
during  the  operation.  The  evidence  of  these  extra  cystic  haemor- 
rhages was  so  marked  and  peculiar,  that  I  am  sure  a  diagnosis  coidd 
be  made  with  certainty  in  similar  cases.  This  would  be  a  great  gain, 
because  it  would  enable  one  to  operate  before  the  frequent  losses  of 
blood  had  weakened  the  patient,  and  while  the  cyst  was  small,  and 
could  be  more  easily  removed — two  advantages  which  would  tend  to 
the  safety  of  the  patient. 

There  were  several  unfortunate  incidents  in  the  operation  which 
could  have  been  in  part  prevented  had  I  had  more  experience  in 
such  cases.  In  the  first  place,  when  the  patient  was  anaesthetized, 
the  cyst  was  handled  with  considerable  force  for  the  purpose  of  de- 
termining the  presence  and  extent  of  the  adhesions.  This,  I  am 
sure,  started  the  bleeding,  which  might  have  been  avoided.  When 
the  cyst  was  opened,  and  the  active  haemorrhage  detected,  I  should 
have  found  the  pedicle,  and  temporarily  controlled  it  with  com- 
pression-forceps. This  would  have  saved  much  of  the  hoemorrhage, 
and  then  I  could  have  taken  time  to  treat  the  adhesions  properly. 

These  facts,  I  believe,  explain  fully  the  failure  in  the  case,  and 
they  throw  much  valuable  hght  on  the  diagnosis  and  treatment  of 
this  peculiar  variety  of  ovarian  neoplasm. 

Ovarian  Cyst  between  the  Folds  of  the  Broad  Ligament.  Incom- 
plete Removal  of  the  Cyst ;  the  Remaining  Portion  treated  with  Drain- 
age ;  Recovery. — This  lady  was  thirty-five  years  old,  and  had  been 
38 


578  DISEASES   OF  WOMEN. 

married  nineteen  years.  Her  general  health  had  been  fairly  good^ 
but  she  did  not  menstruate  until  she  was  nineteen  years  of  age. 
The  menstrual  flow  had  always  been  scanty  and  of  short  duration, 
and  she  never  had  been  pregnant. 

These  facts  indicated  that  probably  the  sexual  organs  were  im- 
perfectly developed.  About  one  year  before  she  came  under  my 
care  she  noticed  a  small  tumor  in  the  right  side  of  the  abdomen,  low 
down.  It  steadily  increased  in  size,  and  then  she  lost  flesh  and 
strength,  and  suifered  from  pain  in  the  abdomen  and  back,  and  her 
appetite  failed.  When  flrst  seen  by  me  she  had  a  bronzed  appear- 
ance, was  feverish,  and  the  pulse  was  fast  and  rather  weak.  She 
had  the  general  appearance  of  one  in  the  last  stage  of  ovarian  dropsy, 
and  also  cachectic.  The  tumor  was  about  the  size  of  the  uterus  at 
the  seventh  month  of  pregnancy.  It  was  very  hard,  and  fluctuation 
was  very  indistinct.  Though  not  apparently  adherent  to  the  abdomi- 
nal wall  the  tumor  was  not  at  all  movable.  It  was  firmly  fixed  in 
the  pelvis,  and  there  was  much  tenderness. 

By  the  vaginal  touch  the  hard  tumor  was  found  deep  down  in 
the  pelvis,  firmly  fixed,  and  not  the  slightest  fluctuation  or  elasticity 
could  be  detected.  The  uterus  was  pushed  to  the  left  and  upward, 
so  that  it  partly  occupied  the  left  iliac  fossa.  The  irregularity  of 
the  surface  of  the  tumor,  as  felt  through  the  vagina,  indicated  that 
it  was  surrounded  by  the  products  of  inflammation. 

The  physical  signs,  as  observed  by  the  vaginal  touch,  were  such 
as  would  indicate  a  uterine  fibroid  developed  in  the  right  broad  liga- 
ment, but  the  character  of  the  tumor,  as  felt  in  the  abdomen, 
showed  that  it  was  a  cyst.  The  question  of  fibro-cyst  was  then 
raised,  but  the  history  of  the  case  was  not  in  favor  of  this.  While 
there  was  little  doubt  regarding  the  true  nature  of  the  tumor  I  fav- 
ored the  diagnosis  of  ovarian  cyst  complicated  by  inflammation  of 
the  cyst-walls. 

The  patient  was  placed  under  treatment  in  the  hope  of  improving 
her  digestion  and  general  health,  but  beyond  relieving  her  consti- 
pation and  flatulence  there  was  no  real  gain.  Her  pulse  remained 
about  98,  and  her  temperature  fluctuated  between  99°  and  101°. 
During  the  few  days  that  she  was  under  observation  the  cyst  became 
a  little  less  tense  so  that  fluctuation  could  be  more  surely  made  out. 

The  chief  points  of  interest  in  the  operation  were  as  follows.  The 
tumor,  easily  and  fully  exposed  by  an  incision  three  inches  long 
through  the  abdominal  walls,  was  adherent  to  the  omentum  over  its 
entire  anterior  surface.  The  cyst  was  emptied  by  aspiration  of  its  con- 
tents which  contained  pus  and  lymph.     The  omentum  w^as  hgated 


ILLUSTRATIVE   CASES  OP  OVARIAN  NEOPLASMS.  579 

in  sections  with  silk,  and  detached  from  the  cyst-wall.  It  was  then 
found  that  the  folds  of  the  broad  ligament  covered  the  cyst  com- 
pletely, and  were  so  intimately  blended  with  the  walls  of  the  cyst 
that  they  could  not  be  separated  to  any  extent.  Careful  and  persist- 
ent efforts  were  made  to  enucleate  the  cyst,  but  in  vain.  The  open- 
ing in  the  cyst  was  temporarily  closed  with  forceps,  and  the  left 
ovary  looked  for.  It  was  found  far  over  on  the  left  side  and  con- 
tained several  small  cysts.  It  was  removed  in  the  usual  way.  The 
major  portion  of  the  cyst-walls  and  broad  ligament  was  then  re- 
moved, and  the  larger  vessels  ligated  to  control  hemorrhage.  An- 
other effort  was  made  to  enucleate  the  remainder  of  the  cyst-walls, 
but  they  extended  so  deep  down  into  the  pelvis  and  the  tissues  were 
so  exceedingly  vascular  and  matted  together  by  inflammatory  prod- 
ucts that  it  could  not  be  done.  The  remains  of  the  ligament  and 
cyst-walls  were  carefully  stitched  to  the  abdominal  wound,  the  sac 
cai-efully  sponged  clean,  and  a  large  drainage-tube  introduced. 

The  after-treatment  and  progress  of  the  case  were  as  follows  : 
She  had  for  the  first  two  days  considerable  nausea  and  pain.  For 
this  she  was  given  hypodermic  injections  of  morphine.  The  sac 
was  washed  out  thoroughly  every  four  or  eight  hours  according  to 
her  temperature.  There  was  not  much  nourishment  taken  dm-ing 
the  first  six  days.  The  pulse  and  temperature  varied  greatly.  The 
pulse  kept  above  one  hundred  most  of  the  time,  and  the  temperature 
fliTctuated  between  100°  and  102°  and  occasionally  103°,  but  this 
high  temperature  never  lasted  long  at  a  time. 

During  the  first  ten  days  the  morphine  was  required,  and  stimu- 
lants had  to  be  used.  In  spite  of  the  frequent  washing  out  of  the 
sac  and  free  drainage  there  was  some  blood-poisoning.  Quinine 
was  freely  given  (whenever  the  temperature  went  up)  by  the  rec- 
tiun  and  by  inunction.  From  the  twelfth  day  onward  there  was  not 
much  of  interest.  The  patient's  nutrition  was  poor,  the  pulse  and 
temperature  kept  a  little  above  normal,  and  occasionally  the  temper- 
ature rose  to  101°,  rarely  to  102°.  The  sac  cavity  gradually  dimin- 
ished, and  the  discharge  became  less.  At  the  end  of  the  third  week 
the  temperature  was  normal  and  remained  so  afterward.  She  took 
food  well,  and  began  to  gain  strength  and  flesh.  The  cavity  was 
very  small,  and  the  di'ainage-tube  used  was  a  piece  of  a  ISTo.  10  elas- 
tic catheter.  The  wound  had  completely  healed,  except  where  the 
tube  was  in  place,  at  the  end  of  the  fourth  week. 

Five  weeks  after  the  operation,  and  when  the  patient  was  up 
and  apparently  about  well,  there  came  a  swelling  quite  hard  at  the 
side  of  the  sinus,  and  the  temperature  went  up  to  102°.     It  was  sus- 


580  DISEASES   OF   WOMEN. 

pected  that  an  abscess  was  forming  there,  and  in  the  hope  of  reach- 
ing it,  if  suppuration  occurred,  the  opening  was  enlarged,  and  a 
tube  of  greater  caHber  introduced,  but  the  swelling  entirely  subsided 
and  the  tube  was  removed. 

The  patient  was  discharged  in  good  condition  two  months  after 
the  operation. 

A  Medium-sized  Ovarian  Cyst  which  could  not  he  removed  owing  to 
the  Character  of  the  Adhesions ;  treated  by  Drainage ;  Recovery. — 
The  patient,  a  German  lady,  thirty-four  years  of  age,  was  admitted 
to  the  hospital,  and  gave  the  following  history  :  She  had  had 
several  children  and  had  noticed  a  "  lump  "  in  the  abdomen  about 
one  year  before  my  first  examination.  This  gradually  but  slowly 
increased,  and  at  times  there  was  pain  but  not  severe,  until  about 
four  months  after  she  discovered  the  tumor.  At  that  time  she 
was  seized  with  violent  pain  in  the  abdomen,  especially  on  the 
right  side.  According  to  the  history  she  evidently  had  at  that  time 
a  severe  inflammation.  This  slowly  subsided  under  the  care  of  her 
family  physician,  but  she  did  not  regain  her  health,  and  continued 
to  lose  flesh,  her  bowels  were  constipated,  and  there  was  much  pain 
and  tenderness  in  the  region  of  the  tumor.  The  size  of  the  tumor 
increased,  and  it  was  much  more  prominent  on  the  right  side. 

At  my  first  examination,  I  found  the  tumor  firmly  fixed  on  the 
right  side,  the  adhesions  to  the  abdominal  walls  and  viscera  being 
evident  at  all  points,  especially  high  up  in  the  lumbar  region  on  the 
right  side.  The  fluctuation  though  not  clear,  was  sufficiently  so  to 
indicate  that  the  tumor  was  a  monocyst. 

Her  general  condition  was  very  poor,  she  was  greatly  emaciated, 
her  skin  was  bronzed,  and  she  had  the  general  appearance  of  one 
suffering  from  malignant  disease.  Her  pulse  was  feeble,  and  her 
temperature  vai-ied  between  98*^  and  100°.  She  had  pain  and  tender- 
ness in  the  abdomen,  especially  on  moving. 

Efforts  were  made  to  improve  the  general  health,  but  without 
effect.  The  points  of  special  interest  in  the  surgical  treatment  were 
the  following  :  The  abdominal  wall  at  the  point  of  incision  was  very 
vascular,  and  the  adhesions  were  also  thick  and  vascular,  and  were 
with  difficulty  separated  from  the  cyst-wall.  On  tapping  the  sac  it 
was  found  that  the  contents  contained  lymph  and  some  jnis,  show- 
ing that  there  had  been  inflammation  of  the  interior  wall  of  the  cyst. 
On  the  left  side  the  abdominal  wall  was  separated  sufficiently  to  en- 
able me  to  pass  my  fingers  into  the  peritoneal  cavity,  and  there  I 
found  the  intestines  adherent  to  the  cyst-wall.  I  tried  first  to  sepa- 
rate the  adhesions  but  that  could  only  be  done  by  dissection,  and  the 


ILLUSTRATIVE   CASES  OP   OVARIAN  NEOPLASMS.  581 

bleeding  was  such  that  I  had  to  abandon  that  procedure.  I  then  tried 
to  dissect  the  peritonaeum  off  from  the  cyst-wall  and  leave  it  attached 
to  the  intestines,  but  this  was  impossible.  In  a  dissection  about  an 
inch  long  and  half  an  inch  in  width  I  had  to  use  three  ligatures  to 
stop  the  bleeding.  I  also  found  that  every  portion  of  the  sac  was 
fastened  in  by  strong  and  vascular  adhesions  which  I  knew  I  could 
not  separate  without  losing  my  feeble  patient.  The  fact  is  I  could 
not  remove  any  considerable  portion  of  the  sac,  only  a  very  small 
portion  in  front.  I  thoroughly  cleaned  out  the  sac,  and  stitched  the 
edges  to  the  abdominal  wall.  This  was  easily  done  because  the  cyst 
was  adherent  all  round  to  the  abdominal  wall,  except  on  the  left  side. 
A  large  drainage-tube  was  introduced  and  the  sac  washed  out  with 
carbolized  water  twice  or  three  times  a  day.- 

The  patient  did  well.  She  began  to  gain  soon  after  the  opera- 
tion, and  continued  to  increase  in  strength  slowly,  but  without  in- 
terruption ;  at  the  end  of  two  weeks  after  the  operation  the  sac  had 
contracted  very  much,  and  there  was  considerable  suppuration.  The 
long  tube  was  removed,  and  a  shorter  one  was  used  to  maintain  the 
opening  in  the  abdominal  wall.  The  thorough  washing  out  was  kept 
up,  and  about  five  times  in  all  I  distended  the  sac  with  equal  parts 
of  carbolic  acid  and  tincture  of  iodine.  This  destroys  the  secreting 
surface  of  the  sac,  suppuration  followed,  and  the  sac  contracted  grad- 
ually. At  the  end  of  two  months  there  was  little  more  left  than  a 
solid  mass  with  a  narrow  and  not  very  deep  sinus  in  it.  The  patient 
was  sent  home,  and  directed  to  wash  out  the  sinus  daily. 

She  was  not  seen  again  until  five  years  after,  when  she  returned 
to  the  hospital  to  see  my  associate  Dr.  Palmer.  She  had  gi-eatly 
improved  in  appearance,  and  stated  that  she  had  been  quite  well, 
and  had  attended  to  her  household  duties  since  she  left  the  hospital 
after  the  operation.  The  opening  in  the  sac  remained  for  four 
months  after  she  went  home,  but  finally  closed  altogether,  and  gave 
no  trouble  afterward.  She  had  a  ventral  hernia,  which  appeared  at 
the  point  of  the  wound  two  years  after  the  operation. 

I  am  satisfied  that  in  certain  cases  in  which  the  adhesions  are 
extensive  and  very  vascular  that  it  is  safer  to  leave  the  operation 
uncompleted,  and  employ  drainage. 

I  have  had  five  successful  cases  treated  in  this  way,  and  one  very 
bad  case  that  proved  fatal,  but  probably  would  have  recovered  had 
the  patient  not  had  organic  disease  of  the  kidneys,  of  which  she  died. 
Mature  judgment,  based  upon  experience  alone,  can  enable  one  to  de- 
termine when  to  employ  drainage  in  place  of  removal  of  the  tumor. 
The  only  way  to  determine  this  is  to  examine  the  extent  of  the 


582  DISEASES  OP  WOMEN". 

adhesions,  and  whether  or  not  they  can  be  separated  without  injury 
to  the  abdominal  ^ascera.  Should  the  cyst  prove  unmanageable  by 
the  operator,  the  part  of  it  which  can  not  be  removed  should  be  left 
and  treated  by  drainage,  and  washed  out  with  antiseptics.  I  am 
well  aware  that  an  expert  and  experienced  operator  can  manage  very 
formidable  adhesions,  but,  when  an  ojDerator  of  limited  ability  en- 
counters adhesions  that  he  can  not  handle  safely,  he  will  be  more 
sure  of  success  if  he  relies  upon  draining  the  cyst  or  that  part  of  it 
which  can  not  easily  be  removed.  Recovery  is  sometimes  tedious, 
but  generally  sure,  according  to  my  observations. 

The  following  cases  of  suppurating  ovarian  cysts,  reported  by 
Dr.  Keith,  together  with  his  comments  on  them,  are  of  such  great 
value  that  I  quote  them  in  full : 

SUPPURATING  OVARIAN  CYSTS. 

The  following  narratives  help  to  show  that  operation  ought  to 
be  the  rule  of  practice  in  cases  of  acute  suppurating  cysts,  or  when 
typhoid  symptoms  come  on  after  tapping : 

Ten  years  ago,  when  cases  of  ovariotomy  were  few,  and  there 
was  little  to  guide  one  in  unusual  circumstances,  a  young  woman  in 
the  last  stage  of  ovarian  disease  came  to  me  a  long  journey  from  the 
north.  The  fatigue  of  traveling  was  too  much  for  the  strength  that 
was  left,  and  she  arrived  completely  worn  out.  It  did  not  seem 
possible  that,  in  such  a  condition,  life  could  be  prolonged  many  days, 
for  the  pulse  was  almost  imperceptible,  there  was  vomiting  and  diar- 
rhoea, oedematous  limbs,  and  albuminous  urine,  while  a  profuse  fetid 
discharge  was  going  on  from  an  opening  near  the  umbilicus.  The 
intensity  of  this  putridity  was  such  that  one  became  aware  of  it 
before  entering  the  house,  and  the  antiseptics  of  those  days  were 
powerless  to  arrest  it.  Day  after  day  I  went  expecting  and  hoping 
to  find  her  dead,  yet,  though  shriveled  up  like  a  mummy,  with  an 
aspect  scarcely  human,  respiration  went  on  for  nearly  a  month,  the 
brain  retaining  its  clearness,  acutely  alive  to  what  was  going  on 
around.  To  remove  a  putrid  cyst  in  such  a  condition  of  feebleness 
did  not  at  that  time  even  occur  to  me ;  yet,  since  then,  I  have  oper- 
ated more  than  once  under  circumstances  not  less  unfavorable,  and, 
looking  back  upon  this  case  now,  I  think  that  operation  might  have 
turned  out  well ;  certainly  death  after  it  would  have  been  the  more 
merciful  way. 

Soon  again  (December,  1804)  there  came  another  case  of  very 
large  tumor.    The  patient  had  been  jolted  for  some  hours  in  a  coach, 


ILLUSTRATIVE  CASES  OF   OVARIAN  XEOPLASMS.  583 

and,  in  the  hope  of  relieving  the  pain  thus  set  up,  tapping  was  per- 
formed after  her  arrival  The  j^ain  was  not  relieved,  abdominal 
distention  from  flatus  became  excessive,  and  typhoid  symptoms  rap- 
idly set  it.  Fearing  a  repetition  of  the  slow-death  j^rocess — which 
those  wlio  saw  will  not  easily  forget — ovariotomy  was  this  time  per- 
formed during  the  semi-delirium  of  septic  fever.  This  was  proba- 
bly the  first  time  that  surgery  broke  in  upon  an  acutely  inflamed 
peritonceum.  The  intense  lividity,  amounting  almost  to  blackness. 
of  the  abdominal  contents,  and  the  spongy  tenderness  of  inflamed 
intestine,  w^ere  then  strange  to  me,  though  thought  little  of  now. 
Recent  lymph  was  present  everywhere,  adherent  bowel  and  mesen^ 
tery  hedged  in  a  thick-walled  cyst,  the  base  of  which  was  in  a  com^ 
plete  state  of  slough.  Inflammation  had  gone  on  to  gangrene,  and 
there  was  intense  putridity,  just  as  in  the  previous  case.  After  an 
operation  which  went  on  for  two  hours,  the  jDatient  was  placed  in 
bed,  cold,  vomiting,  and  nearly  pulseless.  It  seemed  as  if  we  had 
simply  killed  her,  yet  she  got  rapidly  into  heat,  the  restless  delirium 
at  once  disappeared,  there  were  warm  perspirations,  much  sleep,  and 
a  recovery  without  a  drawback. 

This  case,  which  w^as  at  the  time  fully  reported  in  the  "  Lancet," 
1865,  page  480,  has  been  to  me  as  a  landmark.  Since  then  I  have 
ten  times  met  with  cases  of  acute  suppurating  cyst,  besides  two 
chronic  cases.  In  all  of  these,  save  one,  the  chance  of  ovariotomy 
was  given,  however  hopeless  looking  the  case  might  be.  In  the 
exceptional  case  ovariotomy  would  also  have  been  performed  had  it 
been  possible  to  remove  the  patient  from  her  poor  home  and  un- 
favorable surroundings.  She  was  seen  with  Dr.  Menzies  on  the 
third  day  after  her  fourth  confinement.  He  had  been  called  to  her 
for  the  first  time  only  the  day  before.  A  large  ovarian  cyst  had 
existed  with  at  least  two  of  her  pregnancies.  The  distention  was 
so  enormous  that  urgent  dyspnoea  had  to  be  reheved  at  once  by  taj)- 
ping.  Upward  of  six  gallons  of  fluid,  containing  much  blood  and 
pus,  were  got  away,  and  ovariotomy  was  agreed  on  as  soon  as  she 
could  bear  removal.  This  could  not  be  accomjDlished,  and,  after 
three  weeks,  tapping  was  again  had  recourse  to.  This  time  the  pus 
was  intensely  putrid,  and,  as  the  cannula  got  choked  with  pieces  of 
fetid  lymph,  an  incision,  sufficient  to  admit  two  fingers,  was  made 
into  the  cyst,  and  its  putrid  contents  thoroughly  cleared  out.  For- 
tunately, the  cyst  was  single  ;  a  perfect  recovery  took  place,  and  this 
patient  has  had  two  children  since.  J^Tone  but  the  strongest  of 
women  could  have  borne  the  exhausting  suppuration  that  went  on 
for  nearly  four  months.    Pulse  and  temperature  remained  high,  and 


584  DISEASES  OF   WOMEN. 

of  at  least  six  weeks  of  her  illness  she  has  now  almost  no  remem- 
brance. Recovery  in  such  circumstances  must  be  rare ;  yet  it  may 
be  well  to  note  that  during  the  whole  time  she  was  supported  en- 
tirely on  milk  and  buttermilk,  and  had  no  stimulants  whatever; 
neither  was  there  any  washing  out  of  the  cyst. 

Of  the  ten  more  or  less  acute  cases  operated  on,  eight  recovered, 
while  the  two  clironic  cases  got  well  easily.  During  1872-"r3  sev- 
eral came  about  the  same  time,  and  the  following  series  of  seven 
occurred  in  the  course  of  my  second  hundred  operations  for  ovarian 
tumor,  none  of  which  have  yet  been  published.  To  an  onlooker, 
few  operations  look  so  hopeless  as  those  for  the  removal  of  acute 
suppurating  cysts.  The  general  condition  is  always  unfavorable, 
and,  as  a  rule,  ovariotomy  is  in  these  circumstances  tedious  and  se- 
vere.    To  be  believed  in,  such  cases  need  almost  to  be  seen. 

Suppurating  Ovarian  Cyst;  Ovariotomy;  Recovery. — Mrs.  M., 
aged  thirty-live,  was  sent  to  me  in  the  end  of  June,  1871,  by  Dr. 
Soutar,  of  Golspie.  An  ovarian  tumor  was  detected  toward  the  end 
of  1869.  In  January,  1870,  she  had  severe  abdominal  pain.  After 
a  fortnight's  rest,  this  passed  off,  but  only  to  return  with  increased 
severity.  Loss  of  flesh  and  rapid  growth  of  the  tumor  followed, 
and  it  was  nearly  a  whole  year  ere  she  was  again  able  to  be  out  of 
bed.  During  this  time  her  sufferings,  as  told  by  a  friend,  must 
have  been  great.  Often  for  weeks  together  she  could  not  be  moved 
from  one  position,  while  the  changing  of  her  dress,  or  the  arranging 
even  of  the  bedclothes,  brought  on  such  pain  that  her  cries  were 
heard  in  the  street.  It  was  eighteen  months  after  her  first  illness 
that  she  was  able  to  make  the  journey  to  town.  I  saw  her  after  she 
had  rested  two  days.  The  pulse  was  then  156 ;  the  temperature 
103°. 

She  was  a  tall,  fair-complexioned,  blanched-looking  woman,  ex- 
tremely emaciated  ;  the  lips  and  fauces  w^ere  very  anaemic  ;  the  girth 
at  the  umbilicus  was  forty-six  inches ;  the  lower  part  of  the  tumor 
felt  solid,  but  fluctuation  was  distinct  above  the  umbilicus ;  the  ab- 
dominal wall  was  hard,  thickened,  and  oederaatous  ;  the  skin  even 
in  some  places  feeling  as  if  adherent.  It  was  evident  that  there 
were  adhesions  of  a  very  unusual  nature. 

Two  days  after  this  examination,  with  the  assistance  of  Dr.  Drum- 
mond,  of  Nice,  I  removed  three  gallons  of  thick  pus  by  tapping  some 
inches  above  the  umbilicus.  A  large,  prominent,  hard  tumor  re- 
mained below  this.  Much  relief  followed,  and  for  a  few  days  the 
pulse  and  temperature  somewhat  fell.  In  three  weeks  the  cyst  had 
refilled ;  the  pulse  was  again  rapid  and  feeble,  varying  from  120  to 


ILLUSTRATIVE  CASES  OP  OVARIAN  NEOPLASMS.  585 

160 ;  the  morning  temperature  was  101°  to  102° ;  that  of  the  even- 
ing, 103°  to  104:°,  sometimes  higher.  The  skin  was  dry  and  shriv- 
eled, and  she  was,  if  possible,  thinner  than  before. 

Ovariotomy  was  performed  on  the  13th  of  July,  1871.  Sul- 
phuric ether  was  given.  The  incision  extended  from  the  umbilicus 
downward  eight  inches.  The  wall  was  much  thickened,  the  peri- 
toneum of  almost  cartilaginous  hardness,  and  the  whole  parts  so  un- 
usually vascular,  that  no  time  had  to  be  lost  in  completing  the  oper- 
ation. The  upper  cyst  was  emptied  of  its  purulent  contents,  the 
lower  semi-solid  portion  thoroughly  broken  down,  and  the  cyst- 
walls,  weighing  eighteen  pounds,  dragged  out.  There  was  not  any 
part  of  the  tumor  non-adherent.  The  connections  were  of  the  ut- 
most firmness,  especially  those  in  the  pelvis.  Posteriorly,  there  was 
more  adherent  intestine  and  mesentery  than  I  have  met  with  except 
twice.  The  peritonaeum  was  thickened  by  old  lymph.  Large  flakes, 
like  pieces  of  cartilage,  were  peeled  off  the  wall  after  removal  of  the 
tumor.  Some  of  these  were  as  large  as  the  hand,  and  it  was  difficult 
to  tell  what  really  was  the  peritonaeum.  All  bleeding  points  were 
tied  with  Lister's  ligatures,  a  broad,  thick  pedicle  secured  by  a  clamp, 
and  the  wound  closed  with  silk  sutures. 

The  operation  lasted  upward  of  an  hour ;  much  blood  had  been 
lost,  and  she  was  placed  in  bed  with  great  fears  for  her  immediate 
safety.  She  lay  for  some  hours  with  an  almost  imperceptible  pulse. 
She  was  restless,  and  great  bursts  of  clammy  perspiration  broke  out 
every  now  and  then,  such  as  one  sees  in  those  suffering  from  the 
shock  of  injury.  Fortunately,  there  was  no  vomiting.  By  evening 
she  was  comfortably  warm  ;  flatulence  was  troublesome  ;  there  was 
much  thirst.     Pulse,  125  ;  respirations,  32 ;  temperature,  102.° 

She  slept  during  the  night,  but  got  low  and  faint  toward  morn- 
ing, and  there  was  some  vomiting.  Brandy  and  soup  enemata  were 
given  every  two  or  three  hours.  She  improved  toward  evening. 
Flatus  first  passed  forty-four  hours  after  operation.  The  pulse  was 
rapid  and  feeble,  and  she  scarcely  opened  her  lips  for  many  days. 
In  the  third  week  there  was  pain  and  swelling  in  the  right  iliac 
fossa,  and  fluid  fonned.  Four  weeks  after  operation  this  swelling 
was  punctured,  and  about  a  teacupful  of  yellow  serum  was  removed 
by  a  syringe ;  the  rest  was  absorbed.  She  was  able  to  return  home 
in  five  weeks,  and  is  now  a  strong,  healthy  woman. 


CHAPTER  XXXI. 

DISEASES    OF    THE    FALLOPIAN    TUBES. 

Before  considering  the  various  morbid  conditions  of  the  Fallo- 
pian tubes,  I  shall  briefly  review  their  anatomy. 

The  tubes — one  on  either  side — are  contained  in  a  fold  of  the 
peritonaeum  attached  to  the  broad  ligaments,  and  run  transversely 
from  each  lateral  corner  of  the  uterus  out  to  the  ovaries,  to  which 
they  are  joined  by  a  short,  ligamentous  cord.  Each  tube,  or  salpinx, 
is  four  to  five  inches  long ;  the  right  tube  is  usually  slightly  longer 
than  the  left.  The  diameter  increases  from  the  uterus  toward  the 
ovary ;  and  the  canal  similarly  increases.  They  are  formed  of  an 
external  peritoneal  covering,  of  an  internal  mucous  surface,  and  of 
an  intermediate  proper  muscular  tissue,  arranged  in  two  layers,  of 
which  (1)  the  longitudinal  seems  to  be  a  prolongation  from  the 
uterus ;  while  (2)  the  circular,  peculiar  to  the  tubes  alone,  ends  as  a 
kind  of  sphincter  upon  the  abdominal  orifice. 

The  mucous  membrane  is  lined  with  cylindrical  epithelium,  the 
motion  of  whose  cilia  is  toward  the  uterus.  Numerous  fusiform 
cells  are  found  in  an  incompletely  developed  connective  tissue.  The 
arteries  arise  from  the  utero-ovarian  trunk,  entering  the  substance 
of  the  tube  at  its  lower  border.  The  veins  empty  into  corresponding 
vessels.    The  nerves  come  from  the  hypogastric  and  ovarian  plexuses. 

A  study  of  the  development,  in  the  embryo,  of  the  female  organs 
of  generation,  shows  the  closest  structural  relationships  existing  be- 
tween the  tubes  and  uterus.  Some  observers  claim  that  part  of  the 
menstrual  blood  comes  from  the  tubes. 

Anomalies  of  form  and  situation  are  frequent ;  the  tubes  may  be 
absent ;  there  may  be  only  one  tube  ;  alternate  stenosis  and  dilatation 
may  exist ;  and  there  may  be  marked  difference  in  length  between 
the  two  tubes. 

Two  abdominal  orifices  for  a  tube  may  exist,  and  fimbrise  from 
each  may  project  into  the  peritoneal  cavity. 

Again,  the  tul)e  may  be  dislocated,  twisted,  bent  into  knuckles, 
or  may  have  suffered  hernia  along  with  portions  of  the  intestine. 

586 


DISEASES  OF  THE  FALLOPIAN  TUBES.  587 

The  tubes  may  open  into  the  womb  abnormally  low  down,  which 
may  possibly  account  for  placenta  prsevia  in  some  cases. 

J.  AVhitridge  Williams  has  called  attention  to  a  diverticulum 
extending  from  the  lumen  of  the  tube  into  its  wall,  and  reaching 
almost  to  the  peritoneal  covering.  Such  diverticula  he  has  found  to 
be  lined  with  the  typical  single  layer  of  ciliated  epithelium,  and  to 
be  in  all  respects  like  the  tube  itself.  In  speaking  of  this  malforma- 
tion, Williams  says  that  these  diverticula  may  hold  a  causal  relation 
to  tubal  pregnancy.  A  fertilized  ovum  might  readily  be  driven  by 
the  action  of  the  cilia  into  such  a  cul-de-sac,  and  there  develop. 

The  tube  may  be  completely  separated  from  the  ovary.  A  rare 
condition  is  hernia  of  the  mucosa,  where  the  muscular  tissue  is  ab- 
sent, or  so  weak  that  it  allows  the  mucous  membrane  to  protrude, 
forming  a  pocket  into  which  the  fecundated  ovum  may  drop. 

IS'eoplasms  may  be  found  in  the  tubes ;  among  them  tubercle, 
carcinomata,  sarcomata,  cysts,  fibromata,  myomata,  lipomata,  and 
papillomata.  Morgagni's  hydatid  is  a  vesicle  often  hanging  to  a 
fimbria.  Cysts,  tubercles,  and  fibromata  are  the  most  frequent  of 
these  neoplasms,  but  even  these  are  so  rare  that  they  need  only  to 
be  mentioned  here. 

So  many  morbid  tubal  conditions  are  either  direct  or  indirect 
sequelae  of  salpingitis,  or  "  catarrh  of  the  tubes,"  that  this  condition 
first  demands  attention. 

Salpingitis. — Inflammation  of  the  tubes  may  be  acute  or  chronic. 

Pathology. — In  acute  catarrh  the  mucous  membrane  of  the  tube 
is  thickened,  congested,  and  covered  with  neutral  or  acid  mucus, 
muco-pus,  or  an  opaque  fluid  which  contains  lymph-corpuscles  and 
epithelial  cells  which  are  changed  in  form  or  which  have  undergone 
granular  degeneration. 

The  longitudinal  folds  of  the  mucosa  are  effaced  ;  the  fimbria 
are  obliterated  or  obscured  by  inflammatory  products,  and  the  ends 
of  the  tubes  are  usually  closed.  If  not,  the  contents  of  the  tube 
enter  either  the  uterus  or  the  abdominal  cavity,  in  which  latter  case 
pelvic  peritonitis  results.  In  very  severe  cases  (and  sometimes  in 
diphtheria)  false  membranes  may  be  formed  in  the  mucosa. 

Peri-salpingitis  usually  occurs  in  severe  cases.  The  tube  is  in- 
creased in  size,  tortuous,  and  dilated  irregularly,  and  when  the  puru- 
lent secretion  accumulates,  the  tube,  which  is  closed  at  each  end,  be- 
comes greatly  distended.  This  is  known  as  pyosalpinx.  In  this 
condition  the  epithelia  are  flattened  and  the  mucous  and  muscular 
coats  are  gradually  thinned,  so  that  rupture  into  the  peritoneal  cav- 
ity is  not  infrequent,  in  which  case  general  peritonitis  or  pelvic 


588  DISEASES   OF   WOMEN. 

peritonitis  results.  In  rare  cases  the  rectum  has  been  perforated 
and  the  contents  of  the  tube  discharged  through  tliat  viscus. 

Chronic  catarrh  is  accompanied  by  the  adhesions  of  the  tube  to 
the  neighboring  organs  in  some  cases,  the  result  of  localized  perito- 
nitis. The  lower  part  of  the  tube  is  adherent  oftener  than  other 
adjacent  parts.  The  ovary  is  also  congested  or  inflamed  in  the  ma- 
jority of  cases.  The  mucosa  is  much  thickened,  and  secretes  a  fluid 
which  is  either  thin  and  watery  or  thick  and  cheesy,  not  purulent  as 
in  acute  salpingitis. 

Occasionally,  chronic  dropsy  of  the  tube  is  the  result  of  the  secre- 
tion of  serous  fluid,  and  the  tube  may  become  distended  and  form  a 
small  cystic  tumor;  or  it  may  be  converted  into  several  distinct 
cysts  without  any  intercommunication,  since  the  tube  between  them 
has  been  totally  obliterated  by  the  inflammatory  process. 

This  is  known  as  hydrosalpinx.  In  this  condition  all  the  coats 
of  the  tube  sometimes  become  extremely  thin.  Dropsy  of  the 
tube  may  suddenly  terminate  when  an  opening  of  the  duct  into  the 
uterus  occurs ;  this,  however,  is  very  rare. 

Cases  are  recorded  where  a  hydrosalpinx  has  communicated  with 
an  enlarged  and  diseased  ovary. 

Symptoms. — This  affection  so  often  follows  gonorrhoea  or  endo- 
metritis that  the  symptoms  of  salpingitis  are  merged  with  those  of 
the  primary  disease  or  are  completely  masked  by  them,  until  pelvic 
peritonitis  occurs.  This  is  the  most  dreaded  outcome  of  salpingitis, 
and  too  frequently  the  first  symptom  which  leads  one  to  suspect  its 
occurrence.  Usually,  however,  when  salpingitis  occurs  there  is  an 
increase  in  the  symptoms  so  marked  as  to  attract  attention.  The 
pain,  though  less  pronounced  than  that  of  peritonitis,  is  sufticient  to 
compel  the  patient  to  rest  in  the  recumbent  position.  There  is  usu- 
ally some  constitutional  disturbance  or  slight  symptomatic  fever.  In 
acute  cases  this  fever  is  well  defined,  and  attended  with  deranged 
digestion  and  nutrition.  In  short,  it  may  be  stated  that  the  local 
and  constitutional  symptoms  are  the  same  as  in  other  pelvic  in- 
flammations, less  acute  than  in  pelvic  peritonitis  or  pelvic  hfiem- 
atocele,  but  as  well  marked  as  in  pelvic  cellulitis  of  a  mild  type. 
When  pyosalpinx  occurs  there  are  symptoms  of  mild  blood-poi- 
soning. 

Menstrual  disturbances  usually  occur  in  salpingitis,  but  not  al- 
ways. It  frequently  happens  that  the  severity  of  the  symptoms  is 
lessened,  indicating  that  the  inflammation  has  subsided,  but  it  again 
lights  up,  and  becomes  for  a  time  as  marked  as  at  first. 

Periodical  watery  fluxes  with  diminution  in  the  size  of  a  swell- 


DISEASES   OF   THE   FALLOPIAN  TUBES.  539 

ing  in  the  region  of  the  tubes,  and  accompanied  by  colicky  pains, 
are  indicative  of  tubal  dropsy  where  the  tube  is  incompletely  closed 
near  the  uterine  end. 

Physical  Signs. — In  the  first  days  of  the  inflammation,  before 
the  tubes  are  distended,  the  chief  sign  is  tenderness  in  the  region  of 
the  tubes.  When  a  tumor  can  be  made  out  it  is  felt  to  be  elon- 
gated, fluctuating,  movable,  not  separable  from  the  uterus,  and  lying 
on  one  side  in  the  retro-uterine  space. 

By  aspirating,  a  fluid  which  contains  columnar  ciliated  epithelium 
is  found.  Of  twenty-one  cases  in  which  the  fluid  was  examined  by 
my  colleague.  Dr.  F.  Ferguson,  this  epithelium  was  found  in  nine- 
teen. This  is  a  most  valuable  diagnostic  sign,  but  as  aspirating  is 
not  without  danger  it  should  not  as  a  rule  be  resorted  to. 

Excej^t  when  the  tube  is  enlarged  a  positive  diagnosis  of  salpin- 
gitis can  not  be  made. 

The  condition  with  which  salpingitis  is  apt  to  be  confounded  is 
a  small  ovarian  cyst.  It  is  impossible,  often,  to  positively  decide 
this  question  immediately.  By  waiting  and  watching  the  case  the 
ovarian  cyst  will  be  found  to  gradually  become  larger  without  any 
increase  in  the  constitutional  symptoms ;  while  in  tubal  disease  the 
increase  in  size  is  limited. 

Prognosis. — I  believe  that  salpingitis  may  subside,  but  as  a  rule 
the  tube  is  obliterated  entirely  or  in  part.  When  hydrosalpinx  oc- 
curs there  is  not  much  chance  of  recovery.  In  pyosalpinx  recovery 
can  only  be  insured  by  removal  of  the  tube. 

Causation. — Gonorrhoea  of  the  uterine  mucosa  and  simple  and 
puerperal  acute  endometritis  are  its  chief  causes ;  but  it  may  occur 
during  the  course  of  any  acute  infectious  disease,  from  the  presence 
of  neoplasms  or  from  intense  hypersemia  of  the  generative  tract,  as 
in  prostitutes. 

It  is  possible  that  syphilis  may  cause  it,  just  as  it  causes  otitis  or 
ozena.     Sometimes  it  is  secondary  to  diseases  of  the  ovaries. 

Microbes  may  find  entrance  into  the  tubes,  and  on  this  (not  yet 
proved)  statement,  Sanger,  of  Leipsic,  classifies  salpingitis  as  S.  gon- 
orrhoica,  S.  tuberculosa,  and  S.  actinomycotica.  He  also  has  a  sal- 
pingitis septica  including  S.  py?emica,  ichorosa,  purulenta,  and  diph- 
theritica, which  are  due  to  specific  microbes  identical  with  those 
producing  traumatic  infection. 

Treatment. — Acute  and  subacute  salpingitis,  in  the  early  stages, 
should  be  managed  in  the  same  way  as  other  inflammations  of  the 
pelvic  organs  and  tissues.  Best  and  anodynes  for  the  relief  of  pain, 
counter-irritation,  and  attention  to  the  bowels  are  the  chief  indica- 


590  DISEASES   OF   WOMEN. 

tions.  When  the  acute  symptoms  subside,  iodine,  ichthyol,  and 
mercury  have  been  used  locally,  and  massage  and  electricity  also, 
with  some  possible  good  results. 

When  once  hydrosalpinx  or  pyosalpinx  is  developed  it  is  doubt- 
ful if  any  treatment  except  laparo-salpingotomy  is  effective.  Cer- 
tainly this  is  the  case  in  pyosalpinx. 

Laparo-salpingotomy  as  first  practiced  by  Tait  and  Hegar  is  the 
recognized  treatment  in  these  otherwise  incurable  diseases  of  the 
tubes,  and  the  results  are  very  satisfactory.  It  is  not  always  pos- 
sible to  ascertain  whether  hydrosalpinx  or  pyosalpinx  exists ;  hence 
it  is  wise  to  perform  laparotomy  and  remove  the  diseased  tube  if  it 
is  the  seat  of  pyosalpinx  ;  should  a  hydrosalpinx  be  found,  it  may  be 
deemed  best  to  try  stripping  the  tubes  or  catheterizing  and  cleaning 
them  out  and  restoring  them  to  their  normal  situation,  and  trust 
to  curing  the  trouble  thereby.  This  has  been  tried  by  Polk,  but 
the  results  are  not  sufficiently  well  known  to  determine  the  merits 
of  this  procedure.  In  the  former  case  the  woman  is  sterile,  in  the 
latter  not  necessarily  so. 

TUBERCULOSIS   OF   THE   TUBES. 

Pathology. — In  this  condition  the  tubes  are  rigid,  thick,  and 
bound  down  by  pseudo-membranes.  The  thickening  results  from 
infiltration. 

Acute  catarrhal  salpingitis  ordinarily  co-exists.  Both  ends  of 
the  tube  are  usually  closed,  but  between  them  the  cavity  is  much 
dilated,  containing  mucus,  muco-pus,  pus,  or  cheesy  debris.  The 
vessels  of  the  tubes  are  enlarged  and  thickened  and  the  nodules, 
upon  them,  as  well  as  the  nodules  on  the  mucosa  and  in  the  mus- 
cularis,  contain  the  tubercle  bacillus. 

Symptomatology. — The  tubercular  diathesis  which  is  usually 
present  is  the  only  indication  of  the  nature  of  this  affection.  It  may 
be  possible  to  recognize  the  dilated  tube  by  palpating  the  abdomen, 
and  by  manual  examinations  when  its  immobility,  size,  tortuosity, 
and  nodular  feel,  taken  in  connection  with  the  constitutional  condi- 
tions, causes  us  to  suspect  tuberculosis  of  the  tube. 

Possibly  the  dilated  tube  may  be  felt  by  a  vaginal  examination. 
German  gynecologists  advise  that  the  secretions  from  the  uterus 
should  be  examined  for  the  bacilli,  which  if  found  are  evidence  of 
tuberculosis. 

Treatment. — Were  it  possible  to  diagnosticate  isolated  tubercu- 
losis of  the  tubes,  extirpation  would  afford  a  means  of  (possible)  radi- 
cal cure. 


DISEASES   OF   THE  FALLOPIAN   TUBES.  59I 

HiEMATOSALPINX. 

Blood  in  the  tubes  induces  hypertrophy  of  the  walls  except  at 
one  point,  which,  growing  thinner  and  thinner,  forms  a  sac  varying 
in  size  from  a  pin's  head  to  an  orange.  Any  portion  of  the  tube 
may  be  the  seat  of  such  a  tumor.  Fatty  degeneration  or  ulceration 
of  the  walls  of  the  tube  may  induce  rupture  and  peritonitis.  At 
times  the  uterine  end  of  the  tubes  permits  of  partial  or  complete 
evacuation  of  the  tumor. 

Symptomatology. — The  symptoms  are  the  same  as  those  of  hydro- 
salpinx except  that  they  are  more  acute  at  first,  and  at  the  time  of 
the  menses  are  all  markedly  increased  in  intensity. 

Etiology. — Intense  hypersemia  of  the  genitals,  retroversion,  ty- 
phoid fever,  measles,  and  purpura  hgemorrhagica  have  been  known 
to  cause  hsematosalpinx.  When  blood  can  not  make  its  way  out  of 
the  uterus  it  may  flow  back  into  the  tubes.  There  is  no  doubt,  how- 
ever, that  the  mucous  membrane  of  the  tubes  alone  is  capable  of 
being  the  source  of  the  hsemorrhage. 

Treatment. — Laparo-salpingotomy  is  the  proper  treatment,  and  if 
the  diagnosis  is  made  the  tube  should  be  removed  before  peritonitis 
occurs.     The  prospects  of  a  favorable  result  are  then  very  good. 

LAPARO-SALPINGOTOMY    AND    OVARIOTOMY. 

The  operation  for  the  removal  of  the  tubes  and  ovaries  differs  in 
many  respects  from  that  of  ovariotomy  for  cystomata,  and  requires 
a  word  of  description. 

The  incision  in  the  abdominal  wall  should  be  short,  just  sufiicient 
to  admit  two  fingers.  Extra  care  is  necessary  to  avoid  wounding 
the  omentum  or  bowels.  If  the  intestines  are  adherent  to  the  ab- 
donainal  wall,  the  incision  should  be  enlarged  in  order  to  find  a 
part  where  there  are  no  adhesions,  before  opening  the  peritonaeum. 
This  is  easier  than  to  separate  the  intestines.  This  complication  is, 
fortunately,  seldom  met.  I  have  often  found  the  omentum  adherent 
to  the  intestines,  and  occasionally  to  the  abdominal  wall  near  the 
median  line,  but  it  is  generally  free  on  one  or  both  sides,  so  that  the 
tubes  and  ovaries  can  be  reached  by  passing  the  fingers  beyond  the 
adhesions  and  pushing  the  omentum  to  one  side.  When  no  free 
part  can  be  found,  the  omentum  should  be  picked  up  and  divided 
in  the  incision,  and  the  bleeding  vessels  tied.  Two  fingers  should 
be  passed  into  the  wound  and  the  fundus  uteri  found.  This  is  a 
guide  to  the  tubes.  Adhesions,  which  are  usually  present,  should 
be  separated  gently ;  and  when  both  tube  and  ovary  can  be  found. 


592  DISEASES   OF   WOMEN. 

they  should  be  hooked  up  with  the  fingers  and  brought  out  through 
the  wound,  or  into  it.  By  traction  in  tliis  way  a  pedicle  is  found 
and  included  between  the  lingers,  when  it  can  be  transfixed  and 
tied.     The  Staffordshire  knot  is  the  best  to  use. 

Much  skill,  which  can  only  be  obtained  by  practice,  is  required 
to  separate  the  adhesions  and  bring  out  the  tubes  and  ovaries.  If 
tlie  adhesions  are  old  and  can  not  be  broken  up  easily,  it  is  safer  to 
enlarge  the  wound  and  tie  and  divide  them. 

If  the  tubes  are  largely  distended  and  their  walls  thin,  the  adhe- 
sions should  be  separated  only  where  that  can  be  easily  done,  and 
the  tubes  emptied,  or  partially  so,  wnth  the  aspirator,  and  then  seized 
with  the  forceps  and  brought  out  and  the  adhesions  separated.  The 
pedicle  is  then  ligated,  and  tube  and  ovai-y  removed.  Where  there 
are  many  adhesions  there  will  be  some  bleeding,  which  usually  can 
be  stopped  by  pressure,  but  it  is  safe  to  drain  for  a  day  or  so. 

The  after-treatment  is  the  same  as  after  ovariotomy  in  general. 

The  highest  authorities  agree,  at  the  present  time,  that  when 
both  ovaries  and  tubes  are  diseased  and  require  to  be  removed,  the 
uterus  should  be  removed  also.  Various  reasons  are  given  for  this. 
Some  surgeons  contend  that  the  operation  is  more  easily  ])erformed 
than  when  the  uterus  is  left.  This  is  my  own  opinion,  and  I  prac- 
tice accordingly  in  suitable  cases.  When  the  adhesions  are  not  very 
extensive  and  the  disease  of  the  tubes  does  not  extend  close  to  the 
uterus,  a  pedicle  can  be  formed  and  controlled  by  one  ligature,  or, 
better  still,  the  electric  haemostatic  forceps.  I  prefer  to  operate  in 
the  old  way  described  above.  On  the  other  hand,  when  the  disten- 
tion of  the  tubes  extends  close  to  the  uterus  and  the  adhesions  are 
firm,  I  remove  the  uterus  also.  Kelly's  method  is  the  one  for 
which  I  have  preference.  The  operation  is  exactly  the  same  as 
abdominal  hysterectomy,  already  described  in  treating  of  uterine 
fibromata.  At  the  present  time  I  use  the  haemostatic  forceps  in- 
stead of  the  ligature  to  control  the  vessels.  In  this  method  of  oper- 
ating the  cervix  uteri  is  not  removed. 

Those  who  believe  that  the  uterus  is  not  only  a  useless  but  a 
dangerous  organ  after  the  ovaries  have  been  removed,  insist  upon 
complete  extirpation  of  the  uterus  in  all  cases  requiring  double  ova- 
riotomy. Yery  much  has  been  said  and  written  on  this  subject 
within  the  past  few  years,  and  although  many  positive  opinions 
have  been  expressed,  I  fail  to  see  that  they  are  based  upon  sufficient 
clinical  observation. 

For  the  present  I  have  adopted  the  following  rules  of  practice : 
I  completely  extirpate  the  uterus  in  connection  with  laparo-salpingo 


DISEASES   OP   THE   FALLOPIAN   TUBES.  593 

ovariotomy  wlieii  there  is  septic  endometritis  present,  or  any  other 
disease  of  the  uterus  that  does  not  promise  to  disappear  when  the 
ovaries  are  removed,  and  when  there  are  extensive  adhesions  and 
secondary  cehulitis  of  the  broad  ligaments — conditions  tliat  require 
after-drainage.  When  it  is  possible  to  determine  beforehand  that 
complete  extirpation  of  the  uterus  is  indicated,  I  circumcise  the 
vagina  with  the  galvano-cautery,  and  separate  the  uterus  from  the 
bladder  up  to  the  peritonaeum  before  opening  the  abdomen. 

ILLUSTKATIVE    CASES. 

Hydrosalpinx;  Repeated  Discharge  of  the  Contents  of  the  Tube 
through  the  Uterus;  Recovery. — My  friend  Dr.  William  BL.  B.  Pratt 
called  me  to  see  a  rather  delicate  and  very  refined  lady,  who  gave 
a  history  of  some  rather  obscure  pelvic  affection  which  had  existed 
for  more  than  a  year.  The  doctor  found,  when  he  was  first  called 
to  see  her,  that  she  had  a  retroversion  of  the  uterus,  and  presumed 
that  this  was  the  whole  cause  of  her  suffering.  He  was  able  to  re- 
store the  uterus  to  its  place,  but  could  not  keep  it  there,  because 
a  pessary  or  cotton  tampon  caused  great  suffering.  This  was  the 
history  at  the  time  that  I  saw  her.  I  also  learned  that  she  was  un- 
able to  ride  or  walk  for  any  length  of  time,  owing  to  the  severe 
pelvic  and  rectal  tenesmus  which  the  erect  position  brought  on. 
By  a  digital  examination  I  found  the  retroversion  of  the  uterus, 
and  also  a  cystic  tumor,  low  down  on  one  side  of  the  sac  of  Douglas. 
The  tumor  was  oblong  and  elastic,  and  there  was  distinct  fluctuation. 
I  suspected  that  it  was  an  ovarian  cyst. 

Treatment  gave  her  some  relief,  but  she  did  not  recover.  She 
had  repeated  attacks  of  pain  in  the  pelvis,  and  suffered  so  much  on 
taking  exercise  that  she  was  obliged  to  live  an  invalid  life. 

Some  time  after  seeing  her  the  first  time  she  menstruated  more 
freely  than  normal ;  had  more  pain  and  discomfort  than  usual.  Soon 
after  the  menses  she  had  a  sudden  and  free  discharge  of  fluid  of  a 
whitish,  turbid  character,  and  was  much  relieved  after  it.  I  exam- 
ined her  soon  thereafter,  and  found  that  the  cystic  tumor  had  en- 
tirely disappeared.  Her  symptoms,  though  modified  for  a  time, 
returned  again,  and  again  the  tumor  was  found  in  the  same  place. 
Another  discharge  of  fluid  occurred,  followed  by  relief  and  the  dis- 
appearance of  the  tissues. 

This  much  of  the  history,  in  the  way  of  filling  and  emptying  of 

the  tube,  was  repeated  a  number  of  times,  with  this  difference,  that 

the  accumulation  of  fluid  was  less. 

I  regret  that  I  do  not  have  notes  of  the  length  of  time  that  the 
39 


594  DISEASES   OF    WOMEN. 

trouble  lasted,  but  it  will  suffice  to  say  that  the  patient  recovered 
completely,  and  has  had  no  return  of  her  hydrosalpinx  of  seven 
years  ago. 

Double  Pyosalpinx;  Recovery  without  Operative  Interference. — 
The  notes  of  this  case  were  given  to  nie  by  Dr.  Buckniaster.  The 
history  is  a  rare  one,  and  is  of  special  interest.  I  have  in  the  past 
doubted  if  ever  pyosalpinx  ended  in  recovery  without  removal  of 
the  tubes,  but  this  case  shows  that  such  may  occur.  The  patient 
was  twenty-five  years  old,  and  married.  She  had  an  abortion  pro- 
duced, and  peritonitis  and  salpingitis  followed  this  maltreatment. 
Dr.  Buckmaster  saw  her  two  weeks  after  the  time  of  the  abortion. 
Slie  was  then  sufiiering  from  severe  pelvic  inflammation.  The  tem- 
perature was  at  that  time  104°  F.  There  was  marked  pain,  tender- 
ness, and  abdominal  distention.  The  products  of  the  inflammation 
quite  filled  the  pelvis,  and  there  was  fixation  of  the  uterus.  She 
was  treated  in  the  usual  way  by  the  doctor,  and  at  the  end  of  two 
months  from  the  time  that  she  first  came  under  his  care  the  in- 
flammatory products  had  largely  disappeared,  and  the  uterus  was 
slightly  movable,  but  on  each  side  there  were  two  masses  about  the 
size  of  small  lemons.  Several  days  afterward  there  was  a  sudden 
discharge  of  ill-smelling  pus.  On  examination  at  this  time  it  was 
found  that  the  mass  on  the  left  side  had  disappeared.  Soon  after 
this  there  was  another  free  discharge  of  pus,  and  the  mass  on  the 
right  also  disappeared.  For  three  months  subsequently  there  was  a 
slight  but  constant  discharge  of  pus  from  the  cervix  uteri,  but  finally 
it  ceased.  One  year  from  the  attack  the  patient  Avas  in  fair  health, 
but  suffered  from  pelvic  pain  at  times,  which  appeared  to  be  due  to 
adhesions  of  the  peritonitis. 

The  histories  of  many  cases  of  pyosalpinx  might  be  given  in 
which  no  benefit  could  be  obtained  by  general  treatment,  but  were 
promptly  relieved  by  salpingotomy.  In  fact,  the  only  reliable  treat- 
ment for  the  relief  of  this  affection  of  the  tubes  is  to  remove  them. 
The  operation  is  the  same  as  for  the  removal  of  the  ovaries,  and 
need  not  be  described  here.  Those  who  desire  full  details  of  this 
subject  are  referred  to  the  works  of  Lawson  Tait,  Avhose  brilliant 
achievements  in  this  department  of  surgery  were  the  first  and 
greatest. 

IS^o  case  of  haematosalpinx  has  come  under  my  observation,  hence 
the  reader  is  again  referred  to  Lawson  Tait  for  cases  illustrating  this 
6uV)ject. 

Double  Pyosalpinx ;  Amputation  with  Haemostatic  Forceps ;  Re- 
covery.— Entered  Long  Island  College  Hospital,  September  21, 1896. 


DISEASES   OF   THE   FALLOPIAN   TUBES.  595 

D.  G,,  native  of  Norway,  and  sinp^le,  began  to  menstruate  at  thir- 
teen years,  and  regular.  Ten  months  ago  came  to  this  country  ;  had 
amenorrhoea  for  three  months,  then  menstruated  with  severe  pain 
for  one  day  ;  since  then  menses  have  been  normal. 

One  month  prior  to  admission  was  seized  with  severe  pain  in  the 
left  ovarian  region,  which  gradually  extended  to  the  right  and  across 
the  back.  At  this  time  there  was  a  profuse  yellowish  discharge  from 
the  vagina,  together  with  painful  and  frequent  micturition. 

Diagnosis. — Pyosalpinx  (double). 

Treatment. — September  27,  1896,  abdomen  was  opened,  the  ova- 
ries and  tubes  were  freed  from  adhesions,  and  the  broad-ligament 
pedicle  on  either  side  seized  with  the  long  compression  forceps,  cur- 
rent turned  on  and  continued  for  two  and  a  half  minutes.  The  tube 
and  ovary  were  amputated,  when  haemostatic  forceps  were  removed 
and  there  was  no  haemorrhage.  A  number  of  bleeding  points  deep 
down  in  the  pelvis  were  treated  by  the  method  in  question.  Abdo- 
men was  closed  with  silk.  Time  consumed  in  operation,  twenty-five 
minutes. 

Convalescence  progressive  and  uneventful.  Temperature  on 
third  day,  100-5°  F. ;  pulse,  102.  This  was  the  highest  temperature 
until  the  sixteenth  day,  when  it  was  102°  F.  ;  the  next  morning  it 
was  down  to  normal.  Cause  of  rise  unknown.  Sutures  removed 
on  the  eighth  day  ;  primary  union. 

Left  hospital  three  weeks  after  operation. 


CHAPTER   XXXII. 


PELVIC    CELLULITIS. 


The  anatomical  distribution  of  the  pelvic  cellular  tissue  is  the 
same  as  that  in  all  other  parts  of  the  body,  and  its  function  in  this 
region  is  also  the  same  as  elsewhere.  It  fills  in  all  the  interspaces 
between  organs  and  tissues,  being  most  abundant  where  there  is  the 
greatest  mobility,  and  it  is  the  principal  accommodating  and  pro- 
tecting medium  through  which  tlie  blood-vessels  and  nerves 
are  conveyed  to  all  parts  of  the  body.  In  the  pelvis 
it  fills  all  the  unoccupied  spaces  lying  between 
the  pelvic  organs,  except  between  the  perito- 
neum and  the  middle  portion  of  the 
fundus  uteri.  At  that  point  it  ex- 
ists (if  at  all)  in  so  small  a  quan- 


SJIl®™" 


pel'vis- 
toneale 


^mm 


yJI.  lei/cbtor  aai'. 

Fig.  229. — Diagrammatic  transverse  section  of  the  pelvis  (Luschka). 

tity  that  it  can  not  be  demonstrated.  Inflammation  of  the  cellular 
tissue  here  located  has  received  many  names — pelvic  cellulitis,  peri- 
uterine cellulitis,  parametritis,  peri-uterine  phlegmon,  pelvic  abscess, 
and  inflammation  of  the  broad  ligaments. 

I  prefer  the  term  pelvic  cellulitis,  which  was  given  to  it  by  Sir 
James  Y.  Simpson  because  it  indicates  the  nature  and  location  of 
the  disease.    Inflammation  of  the  cellular  tissue  may  occur  wherever 

596 


PELVIC  CELLULITIS. 


597 


that  form  of  tissue  is  found,  hence  the  term  pelvic  cellulitis  does  not 
definitely  locate  the  site  of  the  disease,  and  yet  the  name  is  as  spe- 
cifically descriptive  as  any  of  the  other  terms  used.  Moreover,  pel- 
vic cellulitis,  limited 
to  the  areolar  tissue 
around  the  cervix 
uteri  and  between  the 
folds  of  the  broad  liga- 
ments, comes  under 
the  observation  of  the 
gynecologist  more  fre- 
quently than  in  any 
other  location  in  the 
pelvis  ;  hence  it  should 
be  understood  tliat  the 
term  pelvic  cellulitis 
is  here  applied  to  in- 
flammation of  the  cel- 
lular tissue,  located  in 
the  broad  ligaments 
and  about  the  supra- 
vaginal portion  of  the 
cervix  uteri. 

Pathology.  — This 
differs   in    no  respect 

from  inflammation  of  cellular  tissue  elsewhere,  except  so  far  as  it 
may  be  modified  by  the  peculiarities  of  the  location.  There  is  first 
a  stage  of  active  congestion,  followed  by  an  effusion  of  blood  serum, 
and  later  an  exudation  of  the  higher  organized  constituents  of  the 
blood,  and  finally  suppuration. 

In  some  cases  the  inflammatory  process  stops  short  of  suppura- 
tion, and  the  products  of  the  inflammation  are  removed  by  absorp- 
tion, and  the  recovery  is  soon  completed.  This  is  called  ending 
in  resolution.  There  are  a  few  cases  in  which  the  products  of 
the  morbid  process  are  packed  so  densely  into  the  tissues  that  the 
circulation  is  arrested  and  the  cellular  tissue  destroyed,  and  a  dead 
mass  or  slough  is  formed.  These  cases,  fortunately  rare,  are  very 
severe,  and  sometimes  fatal.  They  are  also  complicated  with  inflam- 
mation of  other  organs  in  the  pelvis,  as  a  rule.  In  fact,  fatal  cases 
are  generally  complicated,  the  uncomplicated  cases  rarely  proving 
fatal.  When  suppuration  takes  place  the  pus  usually  makes  its  escape 
by  some  one  of  the  following  avenues,  mentioned  in  the  order  of 


Fig.  230. — A  section  through  the  sacrum,  the  symphy- 
sis pubis,  and  the  ischia,  to  show  the  cellular  tissue 
on  each  side  of  the  uterus.  The  vessels  are  seen  here 
in  the  bases  of  the  broad  ligaments  and  the  ureters 
are  shown  projecting.  The  lateral  muscular  tissues 
are  the  levatores  ani  and  the  obturators.  (Modified 
from  Freund.) 


598 


DISEASES   OF   WOMEN. 


frequency  as  nearly  as  can  be :  Yagina,  rectum,  bladder,  abdominal 
walls,  saphenous  opening,  pelvic  floor  near  the  anus,  pelvic  foramina, 
obturator  or  sacro-ischiatic  foramen,  and  through  the  pelvic  roof  into 
the  peritoneal  cavity.  I  have  seen  three  cases  in  which  the  pus  from 
an  abscess  in  the  broad  ligament  burrowed  outward  to  the  iliac  fossa, 
and  then  extended  upward  to  the  diaphragm,  and  in  one  it  opened 
through  the  lung  into  the  large  bronchial  tube.  Brief  histories  of 
these  cases  will  be  given  at  the  end  of  this  chapter.  When  the  pus 
escapes  into  the  vagina  or  rectum  at  the  most  dependent  part  of  the 
abscess  sac,  the  evacuation  is  usually  complete  and  the  after-drainage 
favorable ;  the  walls  of  the  abscess  come  together,  and  the  cavity  is 
soon  closed.  The  walls  of  the  sac  become  thin  by  absorption,  the  fix- 
ation and  swelling  of  the  parts  subside,  and  the  recovery  is  complete. 
In  examining  a  case  in  after  years  that  I  had  treated  for  cellulitis 
I  found  that  all  traces  of  the  disease  had  disappeared,  so  far  as  could 
be  ascertained  by  physical  exploration,  and  the  functions  of  the  pel- 


Fio.  231. — Pelvic  abscess  opening 
obliquely  downward. 


Fig.  232. — Pelvic  abscess  opening 
obliquely  upward. 


vie  organs  were  all  performed  normally,  thus  showing  that  the  re- 
covery was  complete.  This  is  the  history  of  the  pathology  of  the 
simplest  cases  of  pelvic  cellulitis. 

When  the  pus  escapes  into  any  other  pelvic  viscera  at  a  ]ioint 
above  the  most  dependent  part  of  the  abscess  sac  the  evacuation  is 
necessarily  incomplete  and  the  drainage  imperfect.  Chronic  sup- 
puration and  discharge  will  occur  under  such  circumstances,  and  the 
duration  of  the  case  is  very  indefinite.  This  is  often  the  result  when 
the  point  of  escape  is  through  the  abdominal  walls  or  the  pelvic 
foramina ;  but  the  same  thing  occurs  sometimes  when  the  opening 
is  into  the  vagina  or  rectum  or  bladder,  especially  the  rectum. 

Judging  from  several  cases  that  I  have  seen  in  which  the  opening 
was  into  the  rectum,  I  am  inclined  to  believe  that  the  direction  of  the 


PELVIC   CELLULITIS.  599 

opening  has  something  to  do  witli  keeping  up  the  suppuration.  "Wlien 
the  opening  is  low  down,  and  enters  the  rectum  obliquely  downward, 
and  the  drainage  is  complete,  the  opening  will  close  promptly  (Fig. 
231) ;  but  if  the  opening  into  the  rectum  is  direct  or  obliquely 
upward,  the  contents  of  the  bowels  will  escape  into  the  abscess  sac, 
and  keep  up  suppuration  for  an  indefinite  length  of  time  (Fig.  232). 

These  conditions  in  the  pathology  of  cellulitis  afford  a  reasonable 
explanation,  perhaps  the  true  one,  of  the  difference  in  progress  be- 
tween cases  that,  up  to  the  time  of  evacuation  of  pus,  appeared  to  be 
alike.  There  is  yet  another  condition  in  the  morbid  products  of 
the  disease  which  retards  recovery.  In  place  of  the  suppurative  pro- 
cess, involving  the  whole  mass  of  inflammatory  products,  a  number 
of  small  abscesses  are  found  producing  a  honey-comb  state  of  the 
parts,  a  number  of  small  abscesses  opening  into  each  other  by  small 
sinuses,  and  all  opening  into  some  of  the  pelvic  viscera,  by  one  or 
more  openings.  This  pathological  condition  delays  the  progress  of 
the  case  greatly.  All  these  exceptional  peculiarities  in  the  pathology 
which  complicate  the  progress  of  the  disease  also  tend  to  make  the 
after-effects — i.  e.,  the  damage  to  the  pelvic  organs — greater.  The 
walls  of  the  abscess  are  thicker,  and  the  scar  left  in  the  tissue  con- 
tracts more,  and  hence  displacements  are  often  found.  Pelvic  pains 
of  a  neuralgic  character  often  follow,  and  the  functions  of  the  pel- 
vic organs,  uterus,  rectum,  and  bladder  are  to  some  extent  occasion- 
ally deranged. 

There  is  still  another  form  of  behavior  noticed  in  some  cases. 
Suppuration  takes  place  at  one  point,  usually  a  small  one,  and  instead 
of  the  pus  escaping  in  the  usual  manner,  it  finds  its  way  into  the 
circulation,  causing  septicaemia,  which  is  intermittent  in  character. 
The  temperature  and  pulse  run  up  high  for  a  time  and  then  sub- 
side, the  fever  being  sometimes  preceded  by  a  chill  or  rigor.  These 
paroxysms  are  repeated  over  and  over  again,  the  general  nutrition 
of  the  patient  being  greatly  impaired. 

Causation. — The  chief  cause  of  pelvic  cellulitis  is  septicaemia,  and 
is  usually  traumatic  in  its  origin.  Injuries  to  the  uterus  and  vagina 
during  parturition  or  abortion  develop  septic  material  which  is  con- 
veyed to  the  cellular  tissue  by  absorption  through  the  lymphatics 
principally.  It  is  possible  that  lymphangitis  is  primarily  developed, 
and  subsequently  cellulitis.  Be  this  as  it  may,  the  fact  is  that  two 
thirds  of  all  the  cases  occur  after  abortion  or  parturition.  Whenever 
cellulitis  follows  parturition,  it  may  be  presumed  that  it  is  caused  by 
the  absorption  of  septic  material  from  the  parturient  canal.  It  is 
possible,  however,  that  contusions  of  the  cellular  tissue  occurring 


600  DISEASES  OF  WOMEN. 

during  parturition  may  give  rise  to  decomposition  of  the  injured 
tissue  and  septic  cellulitis,  which  in  that  case  is  autogenetic,  and 
not  due  to  absorption. 

The  other  and  far  less  common  causes  of  cellulitis  are  surgical 
operations,  the  use  of  caustics,  ill-fitting  pessaries,  dilatation  of  cervix 
uteri  with  sponge  tents  and  direct  blows,  but  with  all  of  these  the 
cause  is  septic,  the  morbid  material  being  developed  by  the  injury. 

Cellulitis  occasionally  occurs  secondarily  to  some  pre-existing  in- 
flammation, such  as  endometritis,  pelvic  peritonitis,  salpingitis,  and 
ovaritis.  These  last-named  affections,  when  they  precede  the  cellu- 
litis, stand  in  a  causative  relation  to  it.  It  quite  frequently  hap- 
pens, however,  that  the  above-named  diseases  are  developed  in  the 
course  of  a  cellulitis,  and  are  caused  by  it,  and  hence  become  com- 
plications of  the  cellulitis. 

The  duration  of  cellulitis  varies  very  much  according  to  the  ex- 
tent of  the  inflammation,  but  more  especially  is  the  progress  modi- 
fied by  the  termination  of  the  inflammatory  process.  In  case  that 
resolution  takes  place,  recovery  may  occur  in  a  few  weeks,  but  on 
the  other  hand,  if  suppuration  occurs  and  the  discharge  of  pus  is 
incomplete,  owing  to  the  unfavorable  point  of  escape,  then  chronic 
suppui'ation  may  go  on  for  months  or  years. 

When  suppuration  takes  place  and  the  discharge  of  pus  is  at  the 
dependent  part  of  the  abscess,  the  average  duration  of  the  disease 
is  about  six  weeks.  Much  has  been  said  about  chronic  cellulitis,  but 
I  have  never  been  able  to  recognize  any  such  condition.  Chronic 
suppuration  in  a  badly-drained  abscess  may  go  on  for  any  length  of 
time — this  we  often  see  ;  also,  frequent  or  repeated  attacks  of  cellu- 
litis may  occur,  but  a  chronic  or  continuous  inflammation  such  as 
we  see  in  inHammation  of  mucous  membranes,  is  something  which  I 
have  never  met  with  in  practice.  This  is  quite  in  accord  with  what 
we  know  of  cellulitis  elsewhere,  where  the  process  begins,  pro- 
gresses, and  ends  and  recovery  follows,  or,  it  may  be,  that  the  inflam- 
mation progresses  to  the  stage  of  suppuration,  and  for  some  reason 
suppuration  is  kept  up,  but  this  is  simply  a  chronic  condition  of  one 
stage  of  the  process. 

I  think  that  the  so-called  chronic  cellulitis,  recognized  and  treated 
as  such  by  some  authorities,  is  nothing  more  than  the  products  of 
the  inflammation  which  remain  after  the  infiammation  itself  has 
subsided. 

The  consequences  of  pelvic  cellulitis  depend  largely  upon  the 
extent  of  the  tissue  involved  and  the  quantity  of  inflammatory  exu- 
date.    Sometimes,  the  tissues  become  infiltrated  with  the  products 


PELVIC   CELLULITIS.  601 

of  the  inflammation  which  do  not  all  break  down  in  the  suppurative 
process;  when  this  occurs,  it  requires  a  long  time  to  effect  the  absorp- 
tion of  these  products,  and  during  that  time  the  patient  is  likely  to 
suffer  from  derangement  of  the  functions  of  the  pelvic  organs  and 
also  from  pelvic  pain.  So,  also,  when  the  products  of  the  inflamma- 
tion have  all  been  disposed  of,  if  much  damage  has  been  done  to  the 
tissues,  which  is  usually  the  case,  contractions  follow  which  are  apt 
to  displace  the  pelvic  organs  to  some  extent,  and  to  give  rise  to 
trouble ;  and  yet,  in  the  majority  of  uncomplicated  cases  of  cellu- 
litis, complete  and  perfect  recovery  generally  takes  place.  This,  I 
have  frequently  been  able  to  verify  by  subsequent  examination  of 
cases  that  I  have  formerly  treated.  More  than  that,  it  not  infre- 
quently happens  that  patients,  after  a  well-deflned  cellulitis,  recover 
and  bear  children,  showing  conclusively  that  the  recovery  was  com- 
plete and  perfect. 

In  the  clinical  history  of  pelvic  cellulitis,  as  manifested  by  the 
symptoms  and  physical  signs  presented,  there  is  a  great  variation  in 
different  cases  ;  just  as  the  extent  of  the  local  lesions  differ  in  degree 
and  extent,  so  the  symptoms  vary  in  their  severity.  There  is  usu- 
ally a  decided  symptomatic  fever  as  indicated  by  the  frequency  of 
pulse  and  elevation  of  temperature.  This  may,  or  may  not  be  pre- 
ceded by  a  chill  or  rigor  which  is  promptly  followed  by  fever. 

The  temperature  as  a  rule  is  not  high,  from  101^°  F.  to  103°  F. 
being  about  the  range.  There  is  also  marked  derangement  of  the 
digestive  organs ;  sometimes,  there  is  some  nausea  and  vomiting, 
almost  always  tympanitic  distention  of  the  bowels,  and  usually  con- 
stipation. It  is  rare  that  there  is  any  delirium  or  very  marked  de- 
pression of  the  nervous  system.  The  patient  usually  complains  of 
pain,  the  intensity  of  which  varies  considerably ;  it  is  usually  most 
marked  in  the  rare  cases  which  arise  from  causes  other  than  parturi- 
tion at  the  full  term. 

When  the  cellulitis  follows  d eh  very,  there  is  abundant  room  for 
the  products  of  the  inflammation  in  the  cellular  tissues  of  the  largely 
developed  broad  ligaments,  and  so  the  pain  which  is  usually  caused 
by  pressure  of  these  products,  is  not  so  great.  In  other  cases  due  to 
injuries,  intercellular  hasmorrhages,  and  the  like,  the  tissues  resist 
the  distention  and  the  exudation,  and  hence  the  pain  is  much  greater, 
and  there  is  usually  decided  disturbance  of  the  function  of  the  pel- 
vic organs. 

If  the  attack  comes  on  when  the  menstrual  period  is  near  there 
may  be  a  menorrhagia.  There  is  also  quite  often  vesical  and  rectal 
tenesmus.    There  is  tenderness  on  deep  pressure  in  the  iliac  regions, 


602  DISEASES  OF  WOMEN. 

and  the  pain  is  usually  aggravated  by  any  movement  on  the  part  of 
the  patient.  This  usually  compels  the  sufferer  to  rest  quietly  on  the 
back.  Occasionally  some  i-elief  is  obtained  by  drawing  up  the 
limbs  while  resting  on  the  back,  but  this  position  is  not  by  any  means 
as  frequently  assumed  and  persistently  maintained  as  in  peritonitis. 
These  symptoms,  both  general  and  local,  usually  continue  without 
much  modification,  except  that  relief  which  may  be  obtained 
through  the  influence  of  medication,  until  the  exudation  is  com- 
pleted ;  then  there  is  usually  a  lowering  of  the  temperature  and 
pulse,  and  relief  from  pain.  The  temperature,  however,  usually  re- 
mains above  100°  F. 

When  suppuration  begins,  there  is  a  renewal  of  the  symptomatic 
fever;  sometimes  a  chill  precedes  this  recurrence  of  fever.  On  the 
other  hand,  if  resolution  takes  place,  the  fever  does  not  return  to 
any  very  great  extent.  During  the  suppurative  process  until  the 
time  when  the  pus  is  discharged,  the  temperature  remains  usually 
above  100°  F.,  sometimes,  suddenly  running  up  to  103°  F.,  indicat- 
ing that  there  may  be  a  little  acute  septicaemia.  When  the  abscess 
opens  and  is  completely  emptied,  there  is  usually  a  prompt  and  al- 
most complete  relief  from  the  symptomatic  fever. 

In  case  that  the  pus  remains  imprisoned  or  is  only  partially  evac- 
uated, and  the  suppuration  and  discharge  continue  to  go  on,  there  is 
usually  marked  constitutional  disturbance,  manifested  by  high  tem- 
perature which  varies  abruptly  in  degree ;  at  times  running  down 
almost  to  normal  and  again  going  up  to  104°  F.,  or  to  104r^°  F. 

Physical  Signs. — These  necessarily  differ  according  to  the  stage 
of  progress  of  the  inflammation.  During  the  stage  of  engorgement, 
a  digital  examination  usually  detects  only  swelling  of  the  parts  and 
tenderness  on  pressure,  and  if  the  examiner's  sense  of  touch  is  very 
acute,  increased  heat  may  be  detected ;  any  effort  to  move  the 
pelvic  organs  will  usually  cause  pain.  When  the  exudation  takes 
place,  the  touch  detects  marked  induration  of  the  parts  involved, 
and  when  it  is  complete,  a  well-defined  tumor  in  both  broad  liga- 
ments will  be  found,  or  it  may  be  that  this  mass  is  found  on  either 
side  of  the  cervix.  If  the  tenderness  when  pressure  is  made  upon 
the  abdominal  walls  is  not  great,  and  there  is  not  much  tympanitic 
distention,  the  tumor  can  sometimes  be  accurately  outlined  by  the 
bimanual  examination.  Usually,  however,  not  much  can  be  accom- 
plished in  this  way  because  of  the  distention  of  the  abdominal 
walls  and  the  tenderness  on  pressure  there. 

The  size  of  the  tumor  of  course  depends  upon  the  extent  of  the 
exudation ;  in  some  cases  it  is  not  larger  than  a  small  orange,  in  oth- 


PELVIC   CELLULITIS.  603 

€rs,  both  broad  ligaments  may  be  split  up,  and  so  filled  with  the 
exudate  as  to  extend  above  the  true  pelvis  and  come  in  contact  with 
the  abdominal  walls,  so  that  the  mass  can  be  easily  identified  by  ab- 
dominal palpation.  This  I  have  seen  in  but  one  case,  though  I  have 
frequently  seen  the  tumor  on  one  side  large  enough  to  be  distin- 
guished in  this  way. 

The  extension  of  the  tumor  upward  out  of  the  true  pelvis,  is 
much  more  frequently  seen  in  cellulitis  following  labor,  and  it  is  a 
physical  sign  characteristic  of  cellulitis  as  compared  with  pelvic  peri- 
tonitis. 

When  the  tumor  occurs  on  one  side,  there  is  usually  displace- 
ment of  the  uterus,  that  organ  being  pushed  in  the  oj)posite  direc- 
tion. When  both  broad  ligaments  are  involved,  the  uterus  may  be 
carried  upward  and  forward.  In  cases  occurring  in  the  non-puer- 
peral state,  the  uterus  is  often  crowded  somewhat  downward ;  in  all 
cases  there  is  most  marked  induration  of  the  parts  presented  to  the 
digital  touch,  and  also  fixation  of  the  uterus.  When  resolution  ter- 
minates the  case,  a  gradual  diminution  of  the  tumor  will  be  observed 
from  time  to  time.  When  suppuration  and  evacuation  take  place, 
there  is  a  more  prompt  reduction  in  the  size  of  the  mass. 

The  physical  signs  sometimes  change  when  suppuration  occurs, 
but  it  is  exceedingly  difficult  to  detect  the  presence  of  pus  in  this 
location,  although  it  is  often  important  to  do  so.  It  is  usually  im- 
possible, also,  to  detect  fluctuation,  because  the  abscess  can  not  be 
touched  at  two  points  far  apart.  One  must  rely  then  upon  the  soft- 
ening of  the  mass  as  felt  by  the  index-finger,  as  the  sign  of  suppu- 
ration. 

This  is  liable  to  be  simulated  by  oedema  of  the  abscess-wall,  but 
this  can  readily  be  distinguished  by  observing  that  the  parts  pit  on 
pressure.  It  often  happens,  however,  that  one  can  not  decide  re- 
garding the  presence  of  pus,  and  if  it  is  of  great  importance  to  so 
determine,  the  aspirating-needle  should  be  employed. 

Treatment. — During  the  first  stage  of  cellulitis,  treatment  should 
be  employed  with  the  view  of  controlling  the  inflammatory  process, 
and,  if  not  able  to  abort  the  trouble,  to  limit  or  circumscribe  it  as 
far  as  possible.  To  accomplish  this,  perfect  rest  should  be  enjoined, 
and  all  pain  relieved  or  made  tolerable  by  the  use  of  opium.  The 
opium  should  be  given  by  the  mouth  in  doses  sufficient  to  give  re- 
lief, and  be  repeated  often  enough  to  maintain  that  relief.  In  case 
the  stomach  is  so  irritable  as  to  refuse  the  opium,  then  it  should  be 
administered  hypodermically. 

There  is  at  the  present  day  some  belief  that  quinine  given  in 


604  DISEASES  OF  WOMEN. 

large  doses  often  controls  or  modifies  local  and  inflammatory  action ; 
this  appears  to  be  so  in  some  specific  inflammations  like  pneumonia, 
and  it  possibly  may  have  some  such  controlling  influence  in  celluli- 
tis ;  if  the  stomach  will  admit  of  it,  no  harm  can  come  from  giving 
ten  or  fifteen  grains  of  quinine  in  a  day  at  the  outset  of  pelvic  cel- 
lulitis, and  possibly  much  good  may  result.  Opium,  however,  is. 
the  chief  agent  when  there  is  much  pain  or  restlessness  in  the  first- 
stage  ;  the  opium  not  only  relieves  the  pain  but  also  keeps  the  bow- 
els at  rest,  which  is  quite  desirable ;  the  bowels,  however,  should 
not  be  kept  too  long  confined ;  in  fact,  I  make  it  a  rule  when  a  case 
is  seen  early,  and  the  rectum  is  distended,  to  empty  it  by  means  of 
a  mild  enema,  then  the  bowels  should  be  kept  quiet  until  the  tem- 
perature and  pulse  come  down  and  the  pain  subsides,  when  the  bow- 
els may  be  again  moved  by  enema ;  this  secures  one  evacuation  be- 
tween the  stage  of  exudation  and  suppuration. 

Local  applications  sometimes  give  the  patient  a  certain  amount 
of  comfort,  and,  when  such  is  the  case,  there  should  be  employed 
warm  poultices,  or,  better,  flannels  wrung  out  of  hot  water,  and  cov- 
ered with  oil-silk. 

The  exudation  may  be  limited  to  some  extent,  it  is  claimed  by 
some  authors,  by  the  use  of  counter-irritants ;  this,  I  think,  is  doubt- 
ful ;  therefore,  if  they  are  used  at  all,  the  milder  agents,  like  mus- 
tard paste,  may  be  employed.  Dui-ing  all  this  time  the  patient 
should  be  nourished  as  well  as  possible.  If  a  vigorous  subject,  less- 
care  in  the  way  of  diet  is  necessary  ;  but,  if  feeble,  an  abundance  of 
nourishing  food  should  be  offered.  Prof.  Virgil  O.  Hardon,  M.  D., 
of  Atlanta,  Georgia,  has  practiced  aspiration  with  good  results  in 
the  stage  of  serous  infiltration.  A  case  illustrating  this  mode  of 
treatment  will  be  given  hereafter. 

When  suppuration  occurs,  the  majority  of  patients  will  bear  at 
that  time  sustaining  means,  nourishing  food,  full  doses  of  quinine, 
and,  in  some  cases,  stimulants.  To  sustain  the  patient  is  the  chief 
object  at  this  stage. 

If  the  case  promises  to  end  in  resolution,  that  should  he  favored 
by  counter-irritants,  and  the  internal  use  of  the  preparations  of  iodine 
combined  with  tonics.  When  the  abscess  opens,  and  discharge  fol- 
lows, sustaining  measures  are  all  that  is  necessary. 

If  suppuration  takes  place,  and  the  pus  is  not  discharged,  the  sac 
should  be  more  freely  opened  and  drained  through  the  vagina. 

When  the  drainage  is  incomplete,  because  of  the  opening  being 
too  high  up,  an  opening  should  be  made  at  the  most  dependent  part 
and  the  drainage-tube  inserted.      In  case  the  imprisoned  pus  can 


PELVIC   CELLULITIS.  605 

not  be  reached  through  the  vagina,  and  the  patient's  life  is  in  danger 
from  chronic  suppuration  or  septicaemia,  the  practice  of  Lawson  Tait 
may  be  adopted — that  is,  opening  the  abdominal  walls,  and  draining 
the  abscess  with  a  drainage-tube  in  the  abdominal  wound. 

The  operation  of  opening  the  abdominal  walls,  and  indirectly 
draining  a  pelvic  abscess,  involves  all  the  difficulties  and  dangers  of 
laparotomy.  It  is  a  very  different  thing  when  the  abscess  sac  is 
adherent  to  the  abdominal  wall.  Making  an  opening  at  the  adher- 
ent point,  and  draining  the  sac,  is  little  more  than  opening  an  or- 
dinary abscess. 

These  are  the  principal  points  in  the  treatment  of  cellulitis ; 
other  details  of  the  clinical  history  and  treatment  will  be  brought 
out  in  the  history  of  cases. 

ILLUSTBATIVE    CASES. 

A  Case  of  Cellulitis  uncomplicated,  ending  in  Suppuration. — When 
this  patient  was  twenty-six  years  old  she  gave  birth  to  her  second 
child.  Tlie  labor,  for  some  reason  unknown  to  me,  was  tedious,  and 
her  physician  delivered  her  with  forceps.  She  progressed  fairly 
well  until  the  fourth  day,  when  she  had  a  chill,  followed  by  fever, 
her  temperature  running  up  to  100°  and  102|^°.  She  also  had  pain 
in  the  pelvis  and  distention  of  the  abdomen,  but  the  lochia  and  milk 
secretion  continued,  although  in  diminished  quantity.  Her  general 
condition  remained  about  the  same,  except  that  she  obtained  relief 
from  opium  given  by  her  physician  until  four  days  afterward.  At 
that  time  I  saw  her,  and  found,  on  examination,  a  large  mass  on 
the  left  side,  tilling  the  upper  portion  of  the  pelvis,  pushing  the 
uterus  to  the  right,  and  extending  above  the  superior  strait,  so  that 
I  could  distinctly  make  it  out  through  the  abdominal  walls.  This 
mass  was  so  closely  united  to  the  uterus  that  it  appeared  to  be  a  part 
of  that  organ,  but  was  as  large  as  the  uterus  itself.  There  was  ten- 
derness to  the  touch,  marked  induration,  and  yet  the  mass  and  the 
uterus  were  very  slightly  movable.  Pain  at  this  time  was  not  great, 
and  the  patient  only  complained  of  a  little  local  distress  and  discom- 
fort, and  said  that  she  felt  weak.  At  the  same  time,  her  pulse  and 
temperature  were  both  above  100. 

There  was  also  laceration  of  the  cervix  uteri,  and  the  discharge 
was  muco-purulent.  At  this  time  she  had  very  little  nourishment 
for  her  child,  and  yet  there  was  a  little.  She  was  directed  to  have 
perfect  rest,  nourishing  food,  opium  sufficient  to  keep  her  free 
from  pain  and  to  secure  comfortable  nights',  with  tonic  doses  of 
quinine. 


606  DISEASES   OF   WOMEN. 

The  disinfecting  vaginal  douche  which  had  been  used  was  con- 
tinued ;  tonic  doses  of  quinine,  with  fluid  extract  of  ergot,  were  or- 
dered three  times  a  day,  and  turpentine  stupes  were  directed  to  be 
applied  to  the  abdomen.  One  week  later  I  saw  her  again  in  consul- 
tation, and  learned  from  her  attendant  that  but  little  change  had 
taken  place  in  her  condition  ;  the  temperature  was  lower,  her  appe- 
tite had  improved,  there  was  almost  no  pain,  and  she  felt  stronger. 
On  examination,  there  was  little  if  any  change  in  the  tumor,  the 
physical  signs  being  about  the  same ;  the  local  discharge  still  con- 
tinued, but  was  less  purulent  and  offensive  ;  the  surface  temperature 
varied  from  time  to  time ;  occasionally  the  skin  was  hot ;  at  other 
times  there  was  free  perspiration.  It  was  impossible  at  this  time  to 
detect  the  presence  of  pus  in  the  mass  in  the  pelvis.  Five  days 
afterward  1  saw  her  again,  when  I  learned  that  she  had  had  a  chill, 
followed  by  a  rise  of  temperature  and  pulse  ;  she  had  also  suffered 
from  rather  profuse  sweating.  At  this  time  her  general  appearance 
was  less  satisfactory ;  she  had  a  somewhat  dusky  hue  of  face,  the 
pulse  also  was  not  as  strong,  and  the  milk  had  stopped  entirely. 
Just  before  the  chill  her  bowels  had  been  moved  by  enema,  and 
both  patient  and  physician  were  disposed  to  attribute  the  increase  in 
her  trouble  to  the  effect  of  the  enema,  but  it  undoubtedly  was  due 
to  suppuration  having  begun. 

On  examination,  the  mass  was  felt  to  be  softer  at  the  most  de- 
pendent part,  and  yet  no  distinct  fixation  could  be  made  out.  Qui- 
nine was  given  in  somewhat  larger  doses,  the  vaginal  douche  was 
continued,  and  a  little  wine  was  added  to  the  bill  of  fare. 

A  few  days  after  this  her  pulse  and  temperature  improved  con- 
siderably. She  had  then  very  little  pain,  but  a  sense  of  heat,  full- 
ness, and  dull  aching  in  the  pelvis.  Four  days  after  this  there  was 
a  copious  discharge  of  pus  from  the  vagina,  followed  by  marked 
improvement  in  the  pulse,  temperature,  and  general  condition.  The 
day  following  a  marked  diminution  in  the  size  of  the  tumor  was 
noticed ;  there  continued  to  be  a  discharge  of  pus  in  diminishing 
quantity  for  nearly  a  week,  but  during  that  time  she  improved  in 
general  condition  very  decidedly.  The  mass  gradually  diminished, 
and  the  uterus  also  progressed  in  involution,  and  her  strength  re- 
turned, so  that  she  became  anxious  to  get  up.  She  was  kept  quiet, 
however,  for  some  time,  until  involution  was  complete,  and  all  that 
remained  of  the  inflammation  was  a  small,  hard,  but  not  tender  mass 
on  the  left  side  of  the  uterus  and  in  the  broad  ligament,  evidently 
the  collapsed  or  the  contracted  walls  of  the  abscess. 

From  this  time  onward  the  improvement  was  steady  and  unin- 


PELVIC    CELLULITIS.  607 

ternipted,  and  she  was  soon  able  to  resume  her  duties,  with  the 
exception  of  nursing  her  child.  At  the  end  of  two  months  from 
the  tinje  of  the  attack,  she  was  quite  well,  and  no  traces  of  her 
trouble  remained  except  a  decided  tliickening  of  the  broad  liga- 
ment. 

A  Case  of  Cellulitis,  ending  in  Eesolution ;  the  Cause  Dilatation  of 
the  Uterine  Canal  by  Sponge  Tent  preparatory  to  curetting. — A  lady 
twenty-eight  years  of  age,  who  had  been  married  seven  years,  had 
suffered  for  some  time  with  menorrhagia,  caused  by  fungosities  of 
the  endometrium,  and,  although  the  cervical  canal  was  quite  empty, 
it  was  deemed  necessary  to  dilate  the  canal  with  a  sponge  tent  before 
removing  the  fungous  growths.  The  sponge  tent  was  introduced 
late  in  the  evening,  and  remained  during  the  following  forenoon ; 
the  curette  was  used  immediately  afterward,  and  the  abnormal 
growths  completely  removed.  Twenty-four  hours  after  this  she 
began  to  have  pain  in  the  region  of  the  left  broad  ligament,  at  the 
same  time  developing  symptomatic  fever,  the  temperature  running 
up  to  101^°  F.,  and  the  pulse  being  accelerated.  She  also  had  a 
Httle  nausea  when  the  pain  was  most  severe,  with  loss  of  appetite 
and  some  tympanitic  disturbance  of  the  bowels.  On  digital  exam- 
ination, made  three  days  subsequently,  a  somewhat  ill-deiined  mass 
was  found  in  the  right  broad  ligament,  which  increased  during  the 
following  forty-eight  hours  until  it  attained  the  size  of  a  hen's  egg. 
There  was  a  little  displacement  of  the  uterus  to  the  right,  but  very 
little.  This  mass  was  quite  tender  to  the  touch,  and  could  not  be 
moved ;  neither  could  the  uterus  be  moved  without  causing  acute 
pain.  Opium  was  given  to  relieve  the  pain,  and  the  bowels  were 
allowed  to  remain  constipated  for  about  four  days.  A  vaginal  douche 
of  borax  and  warm  water  was  used  tvnce  daily,  removing  a  muco- 
sanguinolent  discharge.  The  pain  gradually  subsided,  and  at  the 
end  of  four  or  five  days  the  bowels  were  moved ;  the  fever  also  di- 
minished, the  appetite  slowly  returned,  and  about  this  time  the  mass 
began  to  slowly  ditninish  in  size.  At  the  end  of  two  weeks  the  pa- 
tient was  permitted  to  leave  her  bed  and  sit  in  her  chair,  but  was 
not  allowed  to  take  any  active  exercise  until  after  the  next  menstrual 
period.  During  that  time  she  was  conhned  to  her  bed,  fearing  that 
the  inflammatory  process  might  again  be  lighted  up.  After  the 
period,  which  lasted  about  five  days,  she  was  permitted  to  resume 
her  duties  gradually,  but  was  directed  to  rest  quietly  at  the  next 
menstrual  period,  which  she  did.  Afterward,  on  examination,  it 
was  found  that  the  mass  in  the  broad  ligament  had  wholly  disap- 
peared, there  was  no  tenderness  and  no  evidence  of  congestion  or 


608  DISEASES  OP  WOMEN. 

any  other  trouble,  and  her  subsequent  history  shows  recovery  to  have 
been  complete. 

I  am  quite  sure  that  the  diagnosis  in  this  case  was  correct,  and 
1  am  also  satisfied  that  the  cellulitis  was  caused  by  the  treatment. 
The  case  occurred  at  a  time  in  my  practice  when  I  knew  less  about 
the  management  of  fungosities  of  the  uterus,  hence,  I  used  a  sponge 
tent  before  using  the  curette,  an  entirely  unnecessary  procedure.  I 
know  now  that  there  was  dilatation  enough,  but  I  followed  the 
rules  laid  down  in  the  books,  and  so  employed  the  tent  to  the 
disadvantage  of  the  patient.  I  am  satisfied  also  that  this  case  was 
due  to  sepsis,  for  at  that  time  less  was  known  al)Out  antiseptic  sur- 
gery, and  I  have  no  reason  to  suppose  that  the  sponge  tent  and  the 
instruments  used  were  surgically  clean.  This,  1  believe,  from  the 
fact  that,  although  I  have  often  used  the  curette  since  then  and  oc- 
casionally sponge  tents,  I  have  never  caused  cellulitis.  Uncompli- 
cated cellulitis  rarely  proves  fatal ;  it  is  only  when  peritonitis  super- 
venes that  there  is  much  danger  in  the  early  stages  of  the  disease. 
The  cases  that  end  fatally  do  so  usually  in  one  of  three  ways :  First, 
by  acute  septicaemia,  which  may  take  place  immediately  after  sup- 
puration occurs  ;  second,  by  chronic  septicaemia  and  exudation  from 
prolonged  suppuration  in  badly-drained  cases ;  third,  and  very 
rarely,  when  the  abscess  opens  into  the  peritoneal  cavity,  and  at  once 
sets  up  a  septic  and  usually  fatal  peritonitis. 

Pelvic  Cellulitis  following  a  Haemorrhage  into  the  Cellular  Tissue. — 
A  young,  recently  married  lady,  while  very  much  fatigued  from  un- 
usual physical  exertion,  was  suddenly  seized  with  acute  pain  in  the 
pelvic  region.  When  called  to  see  her,  I  found  her  lying  in  bed 
suffering  from  severe  pain  and  some  rectal  tenesmus  ;  the  pulse  was 
somewhat  accelerated,  but  the  temperature  was  normal ;  the  skin 
moist  and  cool.  There  was  no  constitutional  disturbance  beyond 
nervous  excitation  due  to  pain. 

On  examination,  I  found  a  tender  point  low  down  and  to  the 
right  of  the  uterus,  there  was  also  a  swelling  which  extended  to  the 
right  and  downward  a  little  way,  apparently  between  the  rectum  and 
vagina.  The  pain  was  relieved  by  opium,  and  on  the  following  day 
the  swelling  was  found  to  have  increased  and  become  denser,  and 
yet,  there  was  no  symptomatic  fever. 

Two  days  later  the  physical  signs  remained  the  same,  and  there 
was  also  a  marked  discoloration  or  ecchymosis  of  the  vagina,  especially 
in  the  upper  and  posterior  part  of  its  walls.  This  discoloration,  taken 
in  connection  with  the  history  of  the  case,  satisfied  me  that  the  case 
was  one  of  haemorrhage  into  the  cellular  tissues  of  the  pelvis. 


PELVIC   CELLULITIS.  fjOi) 

The  pain  gradually  became  less  but  there  was  still  a  feeling  of 
fullness  and  pressure  in  the  pelvis  and  an  annoying  rectal  tenesmus, 
which  made  the  patient  feel  as  if  great  relief  would  be  obtained  if 
the  bowels  were  moved.  A  mild  laxative  was  given,  followed  by  an 
enema,  which  secured  a  free  evacuation  of  the  bowels,  but  in  place 
of  relieving,  this  rather  aggravated  her  sufferings.  On  the  sixth 
day  after  the  attack,  the  patient  felt  a  little  chilly,  and  soon  after- 
ward developed  fever  ;  there  was  also  a  slight  recurrence  of  the  acute 
pain  in  the  pelvis.  At  this  time  the  temperature  was  102^°  F.,  and 
the  pulse  about  110. 

On  the  day  following  this,  an  examination  was  made,  and  the 
mass  in  the  pelvis  appeared  to  be  softer  than  it  was  before ;  but  this 
I  think  was  due  to  oedema  of  the  vaginal  walls.  The  fever  con- 
tinued for  several  days  and  then  gradually  subsided,  and  the  tem- 
perature remained  about  100°. 

The  pain  and  general  pelvic  tenesmus  continued,  though  not  in 
a  marked  degree  ;  her  condition  remained  about  the  same  during  the 
follovdng  week,  then  the  pain  became  more  severe,  the  temperature 
rose  a  degree  or  more,  and  she  was  more  restless  and  uncomfortable. 
Two  days  after  this  a  discharge  of  pus  from  the  vagina  occurred,  quite 
profuse  at  first,  and  contmued  in  a  modified  way  for  a  couple  of  days. 

The  discharge  contained  black  specks  which  were  found  to  be 
shreds  of  clotted  blood.  Forty-eight  hours  after  the  discharge  first 
appeared,  a  careful  examination  by  the  touch  was  made  in  the  hope 
of  discovering  the  opening  of  the  abscess,  but  without  success ;  a 
very  careful  speculum  examination  was  then  made,  and  by  the  aid 
of  the  probe  the  opening  was  found  to  the  right  and  a  little  below 
the  cei*vix  uteri.  The  opening  appeared  to  be  just  above  the  mass, 
which  extended  down,  apparently,  between  the  vagina  and  the  rec- 
tum. A  uterine  dilator  of  small  size  was  passed  through  the  open- 
ing into  the  abscess  sac  and  slow  dilatation  made.  When  the  opening 
was  sufliciently  enlarged  to  admit  a  curette,  a  large  piece  of  blood- 
clot  was  removed  ;  several  strands  of  thick,  prepared  silk  were  intro- 
duced into  the  opening  to  keep  up  the  drainage,  and  during  the  next 
few  days  considerable  pus  was  discharged,  together  with  shreds  of 
old  blood-clots. 

As  the  opening  showed  no  disposition  to  close,  the  drainage  was 
abandoned,  and  from  this  time  onward  the  discharge  diminished  and 
the  swelling  and  thickening  of  the  tissues  also  slowly  disappeared. 
Finally,  the  discharge  stopped  altog-ether,  and  thickening  and  indura- 
tion of  the  tissues  gradually  disappeared,  and  complete  recovery  took 

place. 

40 


610  DISEASES   OF    WOMEN. 

Pelvic  Cellulitis  caused  by  Amputation  of  the  Cervix  Uteri. — This 
patient  came  into  the  hospital  about  eighteen  years  ago  with  a  very 
much  enlarged  and  eroded  cervix  uteri ;  in  fact,  the  cervix  seemed 
to  be  divided  into  two  large,  round  masses,  the  surfaces  of  which 
were  very  irregular  and  so  vascular  that  they  bled  profusely  on 
touch.  This  was  before  Dr.  Emmet  had  told  us  about  laceration  of 
the  cervix  uteri  and  its  consequences,  and  I  supposed  that  the  case 
was  one  of  incipient  malignant  disease.  This  diagnosis  was  con- 
curred in  by  several  of  my  colleagues,  and  amputation  of  the  cer- 
vix was  deemed  the  best  mode  of  treatment,  and  the  operation  was 
performed  after  the  method  commended  by  J.  Marion  Sims, 

In  removing  the  posterior  half  of  the  cervix,  I  am  satisfied  that 
I  went  beyond  the  walls  of  the  uterus  into  the  cellular  tissue  ;  sut- 
ures were  introduced  to  bring  the  tlaps  together  and  to  hold  them 
there,  and  the  operation  appeared  to  be  quite  a  success.  At  the 
end  of  the  second  day  the  patient  developed  all  the  constitutional 
symptoms  of  local  inflammation  and  soon  afterward  the  physical 
signs  of  pelvic  cellulitis  were  manifested. 

The  subsequent  history  of  the  case  was  that  of  ordinary  pelvic 
cellulitis  which  ended  in  suppuration  and  discharge,  which  occurred 
at  a  point  corresponding  to  the  right  angle  of  the  junction  of  the 
flaps  made  in  the  amputation.  The  discharge  soon  ceased  and  all 
constitutional  and  local  disturbance  subsided,  and  the  patient  recov- 
ered from  the  acute  attack. 

She  subsequently  did  rather  badly,  there  was  considerable  con- 
traction of  the  scar  left  by  the  amputation,  and  there  was  evidently 
some  contraction  of  the  parts  involved  in  the  cellulitis  so  that  she 
suffered  a  good  deal  in  after  years  with  pelvic  pain  and  dysmenor- 
rhoea,  and  it  became  necessary  to  dilate  the  remaining  portion  of  the 
cervical  canal  in  order  to  give  relief.  This  case  is  mentioned  simply 
to  illustrate  cellulitis  as  it  occurs  after  operations  about  the  cervix 
uteri,  and  it  no  doubt  was  septic  in  its  origin.  The  case  was  treated 
before  the  days  of  antiseptic  surgery,  and  I  have  no  doubt  that  I 
exposed  my  patient  to  all  the  septic  influences  possible  in  such  an 
operation.  Indeed,  the  management  of  the  whole  case  was  rather 
bad  as  it  appears  to  me  now,  and  I  am  inclined  to  believe  that  it  was 
not  at  all  malignant  to  begin  with,  and  that  amputation  of  the  cervix 
was  therefore  uncalled  for.  Such  a  case  now  would  be  considered 
as  a  laceration  of  the  cervix  with  areolar  hyperplasia,  and  would  be 
treated  in  the  usual  way. 

A  Case  of  Pelvic  Cellulitis ;  the  Abscess  opening  into  the  Rectum  and 
liong-continued  Suppuration  occurring  in  consequence. — This  patient 


PELVIC   CELLULITIS.  611 

was  also  seen  in  hospital ;  she  gave  a  history  of  having  had  pelvic 
cellulitis  seven  months  before  admission.  About  live  weeks  from 
the  time  that  she  was  taken  ill  she  had  discharges  of  pus  from  the 
rectum  which  were  followed  by  marked  relief.  After  this  she  con- 
tinued to  have  repeated  discharges  of  pus  in  the  same  way ;  for  a  lew 
days  at  a  time  she  would  be  comparatively  comfortable,  though  never 
well ;  then  she  would  have  a  little  fever,  with  considerable  pain, 
and  then  a  discharge  of  pus,  which  would  give  relief  for  a  few  days. 
These  remittent  attacks  of  pain  and  fever  followed  by  a  discharge 
of  pus,  continued  at  varying  intervals  up  to  the  time  that  I  saw  her. 
On  digital  examination,  I  found  fixation  of  the  uterus,  with  evidence 
of  induration  in  both  broad  ligaments  and  around  the  cervix,  above 
the  vagina. 

She  was  anaemic,  emaciated,  and  had  a  somewhat  cachectic  ap- 
pearance. She  was  placed  under  ether,  and  a  most  careful  examina- 
tion of  the  rectum  made.  The  opening  from  the  rectum  into  the 
cellular  tissue  was  found  about  three  inches  up  the  rectal  wall,  by 
bending  the  probe  into  the  shape  of  a  hook.  I  was  able  to  pass  it 
from  above  downward  and  forward,  showing  that  the  opening  ran 
from  the  rectum  obhquely  downward  into  the  abscess  about  an  inch. 
A  counter-opening  was  made  in  the  most  dependent  part  of  the  sac 
through  the  vaginal  wall ;  the  opening  was  made  with  the  thermo- 
cautery. This  1  believe  to  be  the  best  method  of  making  counter- 
openings  in  these  old  cases,  as  haemorrhage  can  be  avoided  and  the 
lymphatics  closed  by  the  cautery,  which  to  some  extent  guards  against 
septicaemia.* 

The  opening  in  the  vagina  was  maintained  by  small  drainage- 
tubes  which  completely  drained  the  abscess.  The  patient  improved 
generally  and  locally,  and  after  a  time  the  drainage-tube  was  given 
up  ;  a  little  discharge  continued  from  the  opening  for  several  days, 
when  it  closed.  The  case  did  well,  and  was  soon  dismissed  from  the 
hospital,  although  there  still  remained  considerable  induration  and 
thickening  of  the  tissues  of  the  broad  ligaments.  Presuming  that 
her  recovery  would  be  eifected  in  time,  she  was  dismissed  from  the 
hospital ;  but  returned  in  about  tliree  months  with  a  rectal  aliscess, 
which,  when  it  was  opened,  proved  to  be  a  rectal  fistula.  Evidently, 
the  opening  in  the  vagina  had  closed  while  that  in  the  rectum  re- 
mained, thus  forming  an  internal  rectal  fistula.  This  was  treated 
in  tlie  usual  way  and  the  patient  finally  recovered. 

Pelvic  Cellulitis ;  Abscess  discharges  through  the  Saphenous  Open- 
ing.— In  tliis  lady's  fourth  confinement  calcareous  degeneration  of 
the  placenta  was  found.     It  was  retained  for  a  long  time  in  spite  of 


612  DISEASES   OF   WOMEN. 

all  the  ordinary  efforts  used  to  deliver  it ;  it  was  found  necessary  to 
detach  it  from  the  uterus,  a  very  difficult  task.  She  did  very  badly 
from  the  beginning,  soon  developing  a  metritis  and  celhilitis ;  she 
remained  in  a  very  precarious  condition  for  about  two  months ;  the 
products  of  the  inflammation  formed  a  large  mass  on  the  left  side 
which  extended  up  to,  and  finally  became  adherent  to,  the  abdominal 
walls. 

Full  details  need  not  be  given,  suffice  it  to  say,  that  at  the  end  of 
twelve  weeks  an  abscess  opened  through  the  inguinal  canal.  Much 
relief  followed  the  opening  and  the  copious  discharge  of  pus,  but  it 
continued  to  discharge  for  weeks,  and  although  she  had  improved 
after  the  opening  of  the  abscess,  she  began  to  nm  down  from  this 
chronic  suppuration,  and  her  life  was  again  despaired  of.  A  probe 
was  passed  from  the  anterior  opening  and  downward  into  the  pelvis 
until  its  point  could  be  felt  on  the  left  side  of  the  cervix ;  there  was 
still,  however,  a  very  thick  wall  between  the  vagina  and  the  end  of 
the  probe.  After  faithfully  trying  the  effect  of  careful  washing  out 
and  drainage,  without  success,  a  counter-opening  was  made  through 
the  vagina  by  means  of  the  thermo-cautery,  and  a  drainage-tube  carried 
through  the  opening  in  the  abdominal  walls  down  into  the  vagina. 
This  tube  was  injected  three  times  a  day,  and  as  the  patient  improved 
quite  fairly  the  tube  was  drawn  down  toward  the  vagina,  leaving 
the  outer  opening  free.  No  discharge  occurring  at  the  abdominal 
opening  and  the  wound  showing  a  disposition  to  close,  the  tube  was 
gradually  withdrawn,  and  finally  removed  entirely.  The  discharge 
continued  for  some  time  after  the  removal  of  the  tul)(^,  but  finally 
ceased,  and  the  patient  recovered  and  has  remained  well  ever  since, 
a  period  of  eighteen  years. 

Pelvic  Cellulitis  in  which  the  Discharge  was  delayed,  but  finally  re- 
lieved by  Aspiration. — The  history  of  this  case  has  nothing  peculiar 
in  it  excu])t  that  it  progressed  as  cellulitis  usually  does,  until  the 
time  when  the  abscess  was  expected  to  discharge.  It  failed  to  do  so, 
and  the  patient's  general  nutrition  beginning  to  suffer,  it  was  deemed 
advisable  to  use  the  aspirator ;  this  was  done  and  the  abscess,  which 
was  in  the  right  broad  ligament,  was  em])tied  of  about  eight  ounces 
of  pus.  This  gave  great  relief,  but  in  time  the  abscess  filled  again, 
and  again  it  was  aspirated,  Imt  this  time  before  removing  the  needle, 
the  sac  was  carefully  washed  out  with  carbolic  acid  and  water. 
Great  care  was  taken  not  to  inject  quite  as  much  as  the  quantity  of 
pus  removed,  for  fear  that  by  overdistending  the  abscess,  some  thin 
point  in  the  sac  might  rupture  and  cause  mischief. 

There  was  considerable  reaction  after  this  as})iration,  the  pulse 


PELVIC   CELLULITIS.  613 

and  temperature  running  up,  but  soon  subsiding  again.  Nothing 
of  importance  occurred  in  ttie  history  of  the  case,  and  she  recovered 
in  due  time. 

A  Case  of  Cellulitis  terminating  in  Multiple  Abscesses,  cured  by 
enlarging  the  Opening  and  breaking  down  the  Walls  of  the  Small  Ab- 
scesses.— This  case  had  a  history  during  its  early  stages,  quite  in  ac- 
cordance with  the  ordinary  progress  of  tlie  disease,  but  after  suppu- 
ration and  discharge  the  patient  was  not  relieved,  and  the  suppura- 
tion continued.  The  opening  was  found  to  be  a  very  small  one, 
situated  behind  and  to  the  left  of  the  cervix  uteri.  After  trying 
every  possible  means  to  improve  her  general  condition  without 
effect,  the  opening  was  enlarged  by  dilatation,  the  patient  being  an- 
aesthetized ;  after  dilatation,  the  finger  was  passed  up  into  the  mass, 
and  the  walls  of  several  small  abscesses  broken  down.  This  was 
rather  easily  accomplished  because  the  uterus  and  the  mass  of  in- 
flammatory products  were  low  down  in  the  pelvis  and  within  reach, 
and  while  the  finger  was  passed  through  the  opening,  the  other  hand 
was  placed  upon  the  abdomen  to  act  as  a  guide  and  to  guard  against 
breaking  through  into  the  peritoneal  cavity. 

After  this,  the  discharge  was  very  free,  and  a  number  of  shreds 
of  broken  tissue  were  evacuated.  Drainage  was  kept  up  and  the 
parts  washed  out  daily  until  the  mass  had  greatly  diminished  and 
the  discharge  had  almost  subsided.  The  drainage-tube  was  then 
removed  and  the  patient  slowly  recovered. 

A  Tedious  Case  of  Cellulitis  causing  Septicaemia  from  a  Very 
Small  Point  of  Suppuration ;  treated  by  Laparotomy  and  Drainage ; 
Recovery. — This  case  was  seen  in  consultation  with  my  friend 
Prof.  Jewett,  who  gave  me  the  following  notes  :  The  patient  was 
thirty  years  old,  and  was  confined  March  3,  1885,  with  her  seventh 
child.  She  had  ante-partum  haemorrhage  and  inertia  of  the  uterus, 
which  rendered  it  necessary  to  deliver  with  forceps  at  the  superior 
strait.  The  nurse  was  incompetent,  drunk,  or  stupid,  or  all  three, 
and  allowed  the  patient  and  her  bed  to  remain  filthy  for  two  days.  At 
the  end  of  the  third  day,  the  patient  developed  cellulitis  in  the  left 
broad  ligament;  there  was  also  a  circumscribed  peritonitis  limited  to 
the  location  of  the  cellulitis.  At  the  beginning  of  the  disease,  the 
temperature  ran  up  to  103°  and  the  pulse  to  140 ;  this  elevation  was 
attained  on  the  Yth  of  March,  and  from  that  time  until  the  15th,  the 
temperature  ranged  between  100°  and  102°,  and  the  pulse  between 
90  and  110.  There  was  a  marked  difference  between  the  morning 
and  evening  temperature.  From  the  15th  until  the  20th,  the  con- 
stitutional disturbance  subsided,  the  local  inflammation  also  dimin- 


614  DISEASES   OF   WOMEN. 

ished,  and  there  was  every  reason  to  suppose  that  the  cellulitis 
would  end  in  resolution.  From  the  20tli  to  the  28th  she  was  appa- 
rently convalescent,  and  was  able  to  walk  about,  but  on  the  29th  she 
had  a  relapse,  the  temperature  running  up  in  the  afternoon  to  104°. 
The  following  morning  it  was  down  to  97°,  and  from  this  onward 
to  the  18th  of  April  her  temperature  was  most  extraordinary  in  its 
variations.  On  the  4th  and  5th  it  was  105°  in  the  afternoon  and 
lUO°  in  the  morning ;  from  the  6th  to  the  1 1  th  it  ranged  between 
100°  in  the  morning  and  103°  and  104°  in  the  afternoon.  All  this 
also  in  spite  of  quinine  and  other  recognized  antipyretics.  Fi-om 
this  date  to  the  18th,  the  temperature  became  more  irregular,  occa- 
sionally dropping  down  to  9Sf  °,  and  suddenly  and  at  irregular  times 
running  up  to  103°  and  104°, 

It  was  thought  that  this  variation  of  temperature  was  due  to 
septicaemia,  and  yet  no  pus  accumulation  could  be  detected  in  the 
pelvis.  Prof.  Jewett  practiced  aspiration  with  negative  results,  but 
subsequently  made  a  number  of  appointments  for  further  explora- 
tions ;  but  the  patient  was  an  exceedingly  intractable  one,  and  her 
friends  had  no  control  of  her,  so  that  he  was  unable  to  carry  out  his 
wishes  in  this  regard. 

The  physical  signs  during  all  this  time  since  the  relapse  remained 
about  the  same.  The  patient  by  this  time  was  exceedingly  anaemic, 
the  skin  was  of  a  bronze  hue,  and  the  digestion  and  general  nutri- 
tion very  poor,  and  altogether  her  condition  was  critical. 

On  May  2d  she  submitted  to  an  anaesthetic,  and  Prof.  Jewett 
performed  laparotomy.  He  made  an  incision  through  the  abdominal 
walls  directly  over  the  tumor  in  the  broad  ligament,  and,  after  mak- 
ing a  small  puncture  in  the  tumor,  opened  up  the  cavity  with  the 
finger ;  no  pus  was  found,  and  not  more  than  a  teaspoonful  of  septic 
fluid  was  evacuated.  The  cavity  was  drained  and  irrigated  with  a 
bichloride  solution  for  about  four  weeks,  when  it  closed  completely. 

The  temperature  never  rose  above  101°  after  the  operation,  and, 
after  the  first  three  days,  it  became  normal,  and  remained  so  ever 
afterward.  She  raj)idly  gained  in  her  general  health,  and  in  five 
weeks  had  completely  recovered. 

Pelvic  Cellulitis  ending  fatally  from  Septicaemia. — About  sixteen 
years  ago,  while  in  cliarge  of  the  lying-in  department  of  the  Long 
Island  College  Hospital,  one  of  my  cases  developed  a  metritis  and 
cellulitis  after  confinement.  The  case  progressed  in  the  usual  way, 
differing  in  no  respect  from  many  cases  of  the  kind,  except  that 
the  products  of  the  cellulitis  were  unusually  great.  The  metritis 
subsided,  and  the  cellulitis,  which  was  located  in  the  left  broad  liga 


PELVIC   CELLULITIS.  615 

ment,  went  on  to  suppuration,  and,  while  I  was  looking  for  the  ab- 
scess to  discharge,  the  patient  began  to  show  signs  of  septicaemia. 

There  was,  no  doubt,  a  large  accumulation  of  pus  in  the  broad 
ligament,  but,  as  we  were  unable  by  physical  signs  to  determine  that, 
I  unwisely  abstained  from  exploring  the  abscess.  All  constitutional 
treatment  known  to  us  was  carefully  employed,  but  the  patient  died. 
On  post-mortem  examination,  a  very  large  abscess  was  found  in  the 
left  broad  hgament,  and  nothing  more.  The  peritonseum  covering 
the  abscess  was  congested,  and  there  was  much  subserous  oedema, 
but  not  the  slightest  evidence  of  any  peritonitis. 

This  case,  like  many  others,  illustrates  very  well  two  important 
points :  First,  that  cellulitis  occurs  without  the  slightest  pelvic  peri- 
tonitis accompanying  it,  and  this  fact  tells  strongly  against  those 
who  make  no  distinction  between  the  two  affections ;  and,  second, 
if  this  case  had  come  under  my  observ^ation  in  recent  years,  when  I 
appreciate  the  value  of  aspiration  and  abdominal  section  and  drain- 
age, as  taught  by  Lawson  Tait  (all  honor  to  him  for  this !),  the  case 
might  have  been  saved. 

Great  progress  has  been  made  in  the  management  of  cellulitis 
within  the  last  few  years  in  the  employment  of  aspiration,  counter- 
openings,  drainage,  and  abdominal  section  and  drainage,  as  the  above 
cases  have  illustrated. 

Acute  Cellulitis  treated  by  Aspiration  in  the  Stage  of  Serous  Infiltra- 
tion (by  Virgil  O.  Hardin,  of  Atlanta,  Georgia). — ""The  patient  was 
twenty-four  years  of  age,  and  had  borne  a  child  three  months  before. 
The  history  of  the  patient  showed  that  her  menses  had  always  been 
of  nortnal  character  up  to  her  pregnancy,  and  that  she  had  never 
suifered  from  any  symptoms  which  would  indicate  pelvic  disease  of 
any  kind.  Since  her  labor  she  had  had  tenderness  of  the  abdomen 
and  pain  in  walking  and  in  micturition.  Her  general  health,  how- 
ever, had  been  good.  On  the  day  before  I  saw  her  she  was  seized 
with  pain  in  the  back,  pelvis,  hips,  abdomen,  and  thighs.  This  pain 
was  acute  and  excessive.  Micturition  and  defecation  became  very 
painful,  especially  the  latter.  She  had  a  slight  chill,  followed  by 
high  fever,  thirst,  and  complete  loss  of  appetite.  When  seen  by 
me,  she  was  in  bed,  tossing  and  moaning  with  pain,  which  was  re- 
ferred principally  to  the  pelvic  region.  Pulse,  120,  temperature, 
101°,  skin  hot  and  dry,  face  flushed,  tongue  coated.  Vaginal  and 
rectal  examination  were  rendered  impossible  by  excessive  tenderness 
of  the  parts.  The  following  morning  she  was  fully  anaesthetized, 
and  a  complete  examination  effected.  The  vagina  was  hot  and  dry. 
The  cervix  was  lacerated  on  the  left  side.     The  womb  was  low  in 


616  DISEASES   OF   WOMEN. 

the  pelvis,  and  was  pushed  forward  against  the  bladder.  In  the 
posterior  fornix,  and  occupying  the  whole  space  between  the  cervix 
and  the  rectum,  could  be  felt  a  rounded,  bulging  mass,  which  had  a 
boggj,  oedematous  feeling.  By  a  finger  in  the  rectum  this  mass 
could  be  outlined,  and  felt  to  extend  upward  about  an  inch.  No 
fluctuation  could  be  detected,  and,  when  pressed  by  the  finger,  the 
mass  could  not  be  displaced  upward.  Considering  the  condition  to 
be  that  of  pelvic  cellulitis  in  the  stage  of  serous  infiltration,  I  decided 
to  attempt  to  draw  off  the  serum  from  the  cellular  tissue,  hoping 
thereby  to  abort  the  disease  and  prevent  the  formation  of  solid  plastic 
exudation,  with  possibly  a  subsequent  abscess.  Accordingly,  an  as- 
pirator-needle was  thrust  into  the  tumor  from  the  vagina  at  three 
different  points  successively,  and  about  an  ounce  in  all  of  serum 
tinged  with  blood  was  withdrawn.  The  tumor  was  then  found  to 
be  so  softened  and  diminished  in  size  as  to  be  scarcely  perceptible 
to  the  touch.  A  quarter-grain  of  morphine  was  given  hypodermic- 
ally,  and  the  patient  ordered  to  remain  perfectly  quiet  in  bed,  and 
take  only  liquid  diet.  When  seen  twenty-four  hours  later,  she  had 
had  a  good  night's  sleep,  the  pain  in  the  pelvis  was  almost  entirely 
gone,  defecation  was  no  longer  painful,  appetite  had  returned,  the 
pulse  had  fallen  to  80,  the  temperature  to  99°,  and  the  patient  begged 
to  be  allowed  to  get  up.  The  mass  in  the  posterior  fornix  could  be 
felt  only  as  a  slight  thickening.  Two  days  later  the  patient  was  ap- 
parently in  her  usual  health." 

Pelvic  Cellulitis,  with  Certain  Complications,  which,  so  far  as  I 
know,  have  not  been  noticed  or  described  heretofore. — The  patient  was 
thirty-seven  years  of  age,  and  the  mother  of  six  children.  She  was 
confined  in  June,  and  was  fairly  well  for  five  days.  She  got  up  on 
the  fifth  day,  and  tried  to  attend  to  hei'  housework.  Four  days  later, 
while  about  the  house,  she  was  taken  with  severe  pain  in  the  pelvis, 
and  was  obliged  to  take  to  her  bed  again.  This  much  of  her  history 
was  obtained  from  the  patient. 

She  was  seen  for  the  first  time  by  Dr.  J.  H.  Raymond  about  six 
weeks  after  her  confinement,  and  he  learned  that  she  had  had  no 
regular  medical  care,  and  but  very  poor  nursing,  her  poverty  depriv- 
ing her  of  necessary  attention. 

From  the  history  and  physical  signs,  the  doctor  made  the  diag- 
nosis of  pelvic  cellulitis  of  the  left  broad  ligament.  The  tempera- 
ture at  that  time  was  nearly  normal  in  the  morning,  but  rose  to  101° 
or  102°  at  night.  There  was  marked  constitutional  disturbance, 
such  as  generally  obtains  in  long-continued  suppuration  or  septi- 
caemia. 


PELVIC  CELLULITIS.  617 

The  doctor  urged  her  to  go  to  the  hospital,  but  she  declined  until 
August,  about  ten  weeks  after  her  confinement.  During  the  inter- 
val from  the  time  that  she  was  first  seen  until  she  entered  the  hos- 
pital she  was  confined  to  her  bed  with  her  left  thigh  flexed  upon 
the  body,  and  the  leg  upon  the  thigh.  When  she  was  admitted  to 
the  hospital  she  was  very  anaemic,  had  night-sweats,  and  had  the 
general  appearance  of  a  tubercular  patient.  The  flexion  of  the  leg 
and  thigh  continued,  and  there  was  false  anchylosis  of  the  joints. 
The  tumor  in  the  pelvis  was  much  smaller  than  it  had  been,  but 
there  were  pain  and  tenderness  in  the  left  iliac  region,  extending 
up  to  the  lumbar  region.  The  temperature  ranged  from  100°  to 
103°,  being  very  irregular  in  its  rising  and  falling.  There  was  no 
point  in  the  pelvis  where  pus  could  be  detected,  and,  although  there 
was  some  swelling  in  the  left  side  of  the  abdomen,  no  signs  of  pus 
could  be  found  after  repeated  examinations.  She  was  able  to  take 
food  and  stimulants  fairly  well,  and  every  means  was  employed  to 
reduce  the  temperature  and  improve  her  strength,  but  without  any 
favorable  result. 

Hopes  were  entertained  that  the  location  of  the  suppuration 
would  be  found,  and  that  relief  might  be  obtained  by  aspiration  or 
other  means  of  evacuation.  In  spite  of  the  constitutional  treatment, 
she  gradually  declined,  the  anaemia  became  very  marked,  and  the 
temperature  increased,  frequently  being  104:°,  and  sometimes  a  frac- 
tion higher.  She  appeared  to  be  doomed  to  die  of  septicaemia,  and, 
as  a  last  resort,  it  was  decided  to  make  a  laparotomy,  in  the  hopes 
of  finding  the  source  of  the  septicaemia.  Immediately  before  giving 
the  ether  her  temperature  was  lOlf °,  pulse,  140,  and  feeble. 

The  anchylosis  of  the  knee-  and  hip-joints  was  with  difficulty 
broken  up,  and  then  a  more  careful  exploration  of  the  left  iliac 
region  was  made.  There  were  swelling  and  hardening  of  the  wall 
of  the  abdomen  on  that  side,  but  not  to  any  great  extent.  An  as- 
pirating-needle  was  introduced  at  a  number  of  points  in  the  hope  of 
finding  pus,  but  without  avail.  The  abdomen  was  opened,  and  a 
most  careful  exploration  of  the  pelvis  was  made  by  the  touch.  The 
left  broad  ligament  was  considerably  thickened  and  much  less  elastic 
than  it  should  have  been,  showing  the  effect  of  the  inflammation, 
which  had  subsided.  Not  the  slightest  sign  of  any  point  of  sup- 
puration could  be  found,  but,  by  the  bimanual  touch,  with  the  fin- 
gers of  one  hand  in  the  abdominal  cavity,  and  those  of  the  other  on 
the  outside,  I  detected  obscure  fluctuation,  indicating  that  an  abscess 
or  sinus  extended  along  that  side  of  the  abdomen.  The  location  of 
the  pus  having  been  clearly  marked,  the  wound  in  the  abdomen  was 


618  DISEASES   OP  WOMEN. 

closed,  and  an  incision  was  made  in  the  side  down  to  the  pus.  It 
was  found  that  the  pus  cavity  was  very  small  at  its  lower  and  most 
superficial  end.  It  would  not  admit  the  little  finger.  This  ac- 
counted for  the  fact  that  it  was  not  found  with  the  exploring  needle. 
Passing  a  probe  from  the  opening  made  upward,  I  found  that  the 
sinus  was  wider  above,  and  extended  up  to  the  diaphragm.  The 
cavity  was  washed  out,  and  a  drainage-tube  introduced. 

Dr.  Palmer,  who  aided  in  the  operation,  conducted  the  after- 
treatment,  and  the  following  facts  are  taken  from  his  record,  as  kept 
by  the  house-surgeon : 

The  patient  reacted  well  under  the  effect  of  morj^hine  and  atropia, 
given  hypodermically  at  the  end  of  the  operation,  and  again  in  three 
hours.  Whisky  with  hot  water  was  given  four  hours  after  the  opera- 
tion ;  she  retained  it  well,  and  from  that  time  onward  the  morphine 
and  whisky  were  given  to  meet  requirements.  Five  hours  after  the 
operation  the  temperature  was  99^°,  pulse,  128,  respiration,  28.  Two 
hours  later  the  pulse  went  up  to  100^°.  The  night  was  passed  very 
comfortably,  but  she  required  morphine  and  whisky  in  large  doses, 
not  altogether  because  of  the  pain  or  exhaustion,  but  largely  from 
the  fact  that  she  was  used  to  both.  For  years  she  had  been  a  drinker, 
and,  during  the  long  illness  previous  to  the  operation,  she  had  taken 
morphine.  At  five  o'clock  on  the  following  morning  the  tempera- 
ture was  102°,  but  in  two  hours  it  came  down  to  99°. 

From  this  time  onward  her  progress  was  favorable,  at  times  the 
temperature  went  up  one  or  two  degrees,  but  came  down  when  the 
pus  sac  was  w\T,shed  out.  She  improved  in  strength  but  the  sup- 
puration high  up  in  the  cavity  continued,  but  in  a  much  less  degree. 

Her  lung-trouble  j^rogressed  slowly,  but  she  seemed  doomed  to 
pulmonary  phthisis.  One  month  after  the  operation  there  was  still 
a  little  discharge  from  the  wound,  but  she  did  not  apparently  suffer 
from  tliat  to  any  extent,  but  her  cough  was  worse,  and  the  lungs  not 
improving.  At  this  time  she  returned  to  her  home.  The  final  re- 
sults I  have  not  yet  obtained. 

The  following  case  was  similar  to  the  above,  but  terminated 
fatally,  and  a  post-mortem  examination  revealed  the  exact  nature  of 
the  lesions. 

The  patient  was  thirty-seven  years  old,  and  had  been  confined  of 
her  fifth  child  four  months  previous  to  the  time  that  I  first  saw  her 
in  consultation  with  Dr.  P.  L.  Dickinson.  From  the  history  that 
■we  could  gather,  she  had  fever  from  the  day  after  her  confinement, 
and  had  l:)een  sick  ever  since.  She  was  emaciated,  and  her  skin  dry 
and  dusky ;  the  temperature  ranging  from  101°  to  102° ;  she  had 


PELVIC   CELLULITIS.  619 

but  little  appetite,  and  M^as  constipated.  She  rested  on  the  right  side 
with  the  legs  and  thighs  Hexed,  and  complained  of  severe  pain  in 
tlie  right  groin  and  leg.  Owing  to  the  hxed  position  of  the  right 
leg  and  the  great  pain  which  she  suffered  in  moving,  a  physical 
examination  was  not  easily  made.  The  uterus  was  apparently  nor- 
mal and  movable,  but  high  up,  at  or  above  the  brim  of  the  pelvis, 
on  the  right  there  were  evidences  of  inflammatory  products.  The 
diagnosis  of  abscess  in  the  false  pelvis  was  made,  causing  septicae- 
mia. She  was  taken  to  the  hospital,  and  explorations  were  made 
with  the  aspirator,  in  the  hope  of  finding  the  exact  location  of  the 
pus,  but  with  negative  results.  Laparotomy  was  perfonned  by 
Prof.  Charles  Jewett.  The  pelvic  organs  were  normal,  except  that 
there  were  evidences  of  a  former  cellulitis  in  the  upper  portion  of 
the  right  broad  ligament.  The  presence  of  pus  was  made  out  in  the 
right  iliac  and  lumbar  regions  ;  the  abdominal  wound  was  closed,  and 
an  opening  made  above  the  right  groin  into  the  abscess.  It  was 
found  that  the  abscess  cavity  extended  upward  along  the  spine  for 
twelve  inches.  The  subsequent  treatment  consisted  in  washing  out 
the  abscess  cavity,  and  supporting  the  patient  with  nourishment  and 
stimulants.  She  did  not  rally  well,  but  gradually  failed,  and  died 
the  third  day  after  the  operation. 

The  autopsy  showed  that  the  abscess  cavity  extended  from  the 
right  broad  ligament  upward  behind  the  kidney  and  to  the  right  of 
the  spinal  column  to  the  diaphragm.  The  psoas  muscle  was  in- 
volved in  the  abscess,  but  there  was  no  bone-disease,  and  it  was  the 
opinion  of  all  who  attended  the  autopsy  that  the  disease  began  as  a 
cellulitis  of  the  right  broad  ligament. 

A  case  similar  to  the  above  came  under  my  observation  twelve 
years  ago.  Upon  being  admitted,  the  patient  gave  a  history  of  cel- 
lulitis following  confinement.  She  was  in  a  very  low  condition  from 
septicaemia.  I  found  signs  of  suppuration  in  the  left  iliac  region, 
and,  on  making  an  incision,  I  found  a  large  abscess,  which  extended 
upward  to,  if  not  beyond,  the  diaphragm. 

The  patient  had  a  cough  with  purulent  expectoration,  but  no 
well-defined  signs  of  any  disease  of  the  lungs.  After  wasliing  out 
the  abscess  sac  with  carbolic  acid  and  water,  the  patient  declared 
that  she  could  taste  the  acid ;  this  led  me  to  suspect  that  the  abscess 
had  opened  into  one  of  the  larger  bronchi ;  water  colored  with  car- 
mine was  injected,  and  the  matter  expectorated  afterward  was  col- 
ored with  the  carmine. 

She  died  of  exhaustion,  and  at  the  autopsy  it  was  found  that  a  sinus 
extended  up  behind  the  diaphragm  and  opened  into  a  bronchial  tube. 


CHAPTER  XXXIIL 


PELVIC    PERITONITIS. 


The  peritonaeum  which  covers  the  pelvic  viscera  of  the  female 
differs  in  no  respect  in  its  anatomical  construction  from  the  gen- 
eral peritonaeum,  and  its  function  is  the  same.     It  differs  only  in 


Utero-sacral  ligament     Cul-de-sac,  or  utero-rectal  pouch  (Douglas). 
Ureter     |       i 
Ovarian  artery 


Round  litrainciit. . . 
Fallopian  tube , 

Ovary 

L'tero-ovarian  ligament. . 

Bladder i    ip,„„i„^  „f  „,,.r„8 

Fig.  233.— The  pelvic  peritonaeum  as  seen  on  looking  into  the  brim. 


the  organs  which  it  covers,  and  in  the  fact  that  there  is  in  this 
region  a  direct  communication  and  union  between  the  mucous  and 
serous  membranes  at  the  opening  of  the  Fallopian  tubes. 

From  the  fact  that  the  peritonaium  is  a  continuous  membrane, 
one  would  naturally  suppose  that  an  inflammation  beginning  at  one 

620 


PELVIC   PERITONITIS. 


621 


point  would  incline  to  extend  to  tlie  whole  membrane,  so  that  gen- 
eral peritonitis  would  be  the  rule  in  the  pathology  of  inflammation 
of  this  membrane.  It  is  a  fact,  however,  that  the  pelvic  peritonaeum 
becomes  the  seat  of  inflammation  very  often  and  without  any  general 


Fig.  234. — The  reflections  and  pouches  of  the  pelvic  peritona?um  seen  from  behind.  In 
the  center  it  dips  into  the  cul  desac  of  Douglas.  The  lateral  pockets  or  shelves  are 
shallower.     (Modified  from  Ilodge,  American  Text-book  of  Obstetrics.) 


disposition  to  extend  to  the  abdominal  peritonaeum.  The  two  ailec- 
tions,  then — that  is,  pelvic  peritonitis  and  general  peritonitis — while 
they  are  the  same  in  their  pathology,  differ  so  in  their  clinical 
history  and  causation  as  to  render  them  two  separate  and  distinct 
affections. 

There  is  a  form  of  peritonitis  which  occurs  after  parturition,  in 
which  the  inflammation  begins  in  the  uterus  and  extends  to  the 
general  peritonaeum,  and  is  known  as  metro-peritonitis  ;  but  this  also 
differs  entirely  from  pelvic  peritonitis,  which  occurs  far  more  fre- 
quently than  either  general  peritonitis  or  metro-peritonitis. 

The  pathology  of  pelvic  peritonitis  is  the  same  as  in  inflamma- 
tion of  serous  membranes  generally.  There  is  first  subserous  con- 
gestion, followed  by  a  transudation  of  blood  serum,  and  then  an 
exudation  of  plastic  material,  or  the  higher  organized  constituents  of 


622  DISEASES  OP  WOMEN. 

the  blood.  Ordinaril}',  this  ends  the  foniiative  stage  of  the  inflam- 
matoi'y  process,  and  the  products  of  the  intiamniation  are  disposed  of 
first,  by  the  absorption  of  the  serous  transudation  and  the  organiza- 
tion of  the  exudate.  This  organization  simply  consists  in  the  devel- 
opment of  blood  circulation,  either  in  or  beneath  the  exudate,  suffi- 
cient to  maintain  it  in  a  vitalized  condition  and  prevent  its  further 
degeneration  and  disintegration. 

The  peculiar  characteristic  of  this  exudate  is  to  form  adhesions 
to  adjoining  tissues  and  to  undergo  contraction  in  its  after-life,  so 
that  following  an  attack  of  pelvic  peritonitis,  the  parts  in  the  grasp 
of  the  exudate  become  adherent,  and  are  often  drawn  out  of  their 
normal  position  by  its  contraction.  Occasionally,  but  rarely,  the  in- 
flammation of  this  serous  membrane  goes  on  to  suppuration.  When 
this  form  of  peritonitis  takes  place,  pus  accumulates  usually  in  the 
sac  of  Douglas ;  there  it  sometimes  is  walled  in  by  an  exudation  of 
lymph  which  unites  the  two  folds  of  the  peritonaeum  which  fonn 
the  sac.  Occasionally,  too,  small  abscesses  may  be  formed  in  the 
exudate  which  is  thrown  out  around  the  ovaries  and  Fallopian  tubes. 

There  is  a  wide  range  in  the  degree  of  severity  in  cases  of  pelvic 
peritonitis ;  in  some,  a  circumscribed  spot  of  inflammation  may  oc- 
cur which  gives  rise  to  a  little  discomfort  at  the  time,  and,  passing 
off",  leaves  no  suspicion  that  there  ever  had  been  an  inflammation 
there.  These  cases  we  know  occur  from  the  fact  that  the  traces  of 
inflammation  are  found  post-mortem. 

From  these  circumscribed  and  exceedingly  mild  attacks,  we  find 
all  grades  of  severity,  up  to  the  most  marked,  where  the  whole  pelvic 
peritonaeum  is  involved  and  suppuration  occurs,  and  the  case  termi- 
nates fatally.  In  this  respect,  pelvic  peritonitis  strongly  I'esembles 
pleurisy,  the  milder  cases  representing  the  circumscribed,  dry  pleu- 
risy, and  the  more  severe  corresponding  to  that  of  pleuritic  em- 
pyema. 

There  is  also  anotlier  form  of  pelvic  peritonitis,  in  which  there 
is  an  unusual  transudation  of  serum  which  accumulates  in  the  sac  of 
Douglas,  and  corresponds  to  the  ordinary  pleurisy  with  eifusion. 

Judging  from  the  number  of  cases  of  peritonitis  met  in  practice, 
and  also  from  observations  made  post-mortem,  this  is  one  of  the 
pelvic  diseases  which  occurs  perhaps  as  frequently  as  any;  cer- 
tainly, it  is  much  moreconnnon  than  })elvic  cellulitis  uncomplicated. 
It  no  doubt  occurs  most  frequently  in  the  progress  of  other  pelvic 
affections,  like  cancer  of  the  uterus,  pelvic  cellulitis,  sal])ingitis,  etc., 
but  under  these  circumstances  it  is  a  secondary  afl'ection,  and  in 
that  form  need  not  be  discussed  here. 


PELVIC   PERITONITIS.  623 

In  less  severe  cases  the  exudation  gradually  disappears,  and  tlie 
mobility  and  functional  activity  of  the  pelvic  organs  may  be  again 
restored  and  the  patient  may  be  considered  as  having  recovered. 
But  this  takes  a  long  time  before  it  is  accomplished.  When  pelvic 
peritonitis  terminates  fatally,  it  usually  does  so  because  the  inflam- 
mation has  gone  on  to  suppuration,  and  may  be  called  a  purulent 
peritonitis,  and  in  that  case  the  patient  may  die  in  a  few  days  from 


Blase 


Fig.  235. — Retroverted  uterus  bound  back  by  peritonitic  adhesions  ;  a,  h,  adhesions. 

(Winckel.) 

the  time  of  the  attack,  either  from  shock  or  acute  septicaemia,  or 
both,  or  inflammation  may  extend  to  the  general  peritonaeum,  and  in 
that  way  sacrifice  the  patient. 

Causation. — In  regard  to  the  causes  of  pelvic  peritonitis,  we  find 
that  non-parous  women  are  most  liable  to  it,  especially  those  who 
sufier  from  imperfect  development  of  the  sexual  organs  and  de- 
rangement of  their  functions,  like  dysmenorrhoea,  for  example. 

The  immediate  causes  of  pelvic  peritonitis  are  of  three  kinds : 
First,  where  it  is  secondary,  and  evidently  caused  by  some  affection 
or  inflammation  of  some  of  the  other  pelvic  viscera,  like  ovaritis, 
salpingitis,  and  endometritis.  Second,  traumatic  influences,  such  as 
injuries  of  any  kind,  imprudence  during  menstruation,  and  all  sur- 
gical operations  or  treatment.  In  those  who  have  suffered  long 
from  displacements  and  flexions  of  the  uterus  and  general  irritability 
and  congestion,  injuries  appear  to  be  sufficient  to  set  up  a  peritonitis, 
like  the  passing  of  a  uterine  sound,  or  the  application  of  caustics  to 
the  uterus.  Third,  speciflc  causes,  such  as  the  escape  of  septic  mate- 
rial from  the  Fallopian  tubes,  in  cases  of  endometritis  and  salpin- 
gitis, but  more  especially,  the  virus  of  gonorrhoea.  In  a  large  num- 
ber of  cases  the  cause  will  be  found  in  this  speciflc  virus  ;  this  is 
the  reason  why  pelvic  peritonitis  is  such  a  common  affection  among 
prostitutes. 


(524  DISEASES  OF   WOMEN. 

The  duratioD,  termination,  and  after-consequences  of  pelvic  peri- 
tonitis, depend  largely  upon  the  extent  of  the  inflanimation  and  the 
cause  which  gives  rise  to  it.  In  some  cases  where  the  exudation  is 
limited  recovery  will  take  place  in  a  few  weeks,  and  but  little  after 
ill  effects  will  be  noticed,  except  occasional  pain  from  time  to  time 
in  the  region  of  the  exudate.  In  other  cases  where  the  whole  pel- 
vic peritonjBum  is  involved,  the  limbriated  extremities  of  the  Fallo- 
pian tubes  become  involved  in  the  exudate,  and  are  virtually  de- 
stroyed. If  this  includes  both  sides,  the  function  of  the  ovaries 
and  tubes  is  arrested  because  of  the  damage  to  the  structure. 

Degeneration  of  the  ovaries  often  follows  under  these  circum- 
stances ;  sometimes  they  become  inflamed  and  succulent ;  at  other 
times  they  become  atrophied,  due,  no  doubt,  to  the  pressure  of  the 
contracting  exudate  and  the  interruption  of  the  circulation  in  them ; 
in  short,  in  some  of  these  cases,  the  adhesions  and  the  quantity  of 
exudation  so  destroy  the  anatomical  relations  that  on  post-mortem 
it  is  almost  impossible  to  recognize  the  tissues  or  organs.  A  mass 
of  tangled  adhesions  and  products  of  inflammation  covering  the 
uterus  and  broad  ligaments,  is  about  all  that  can  be  made  out. 

When  such  patients  live,  they  suffer  greatly  from  pelvic  pain 
and  dysmenorrhoea,  if  the  function  of  menstruation  is  not  arrested, 
as  it  sometimes  is,  by  the  destruction  of  the  ovaries. 

Symptomatology. — This  varies  according  to  the  severity  of  the 
attack  ;  in  average  cases  there  is  a  well-deflned  symptomatic  fever, 
the  pulse  being  characteristic  of  inflammation  of  the  serous  mem- 
branes, being  small  and  wiry,  and  running  up  from  110  to  130  ;  the 
temperature  is  variable,  often  running  to  103°  F.  and  104°  F.,  and 
in  severe  cases  to  100°  F. 

At  flrst,  the  skin  is  usually  dry  and  hot ;  there  is  marked  de- 
rangement of  the  digestive  organs,  nausea  and  vomiting  often  occur- 
ring ;  sometimes  in  the  severer  cases  vomiting  of  that  greenish  ma- 
terial so  common  in  general  peritonitis,  occurs.  There  is  usually 
marked  tympanitic  distention,  and  the  patient  prefers  resting  quietly 
on  the  back  with  the  limbs  drawn  up,  a  position  which  seems  to  be 
the  easiest ;  there  is  usually  a  considerable  disturbance  of  the  nei'v- 
ous  system,  the  patient  being  anxious,  restless,  and  the  facial  ex- 
pression showing  anxiety  and  dread.  Sometimes  there  is  delirium, 
but  not  usually,  and  when  it  does  occur,  I  am  inclined  to  think  it 
shows  that  the  ovaries  are  affiected ;  at  any  rate,  and  in  several  cases 
that  I  have  seen,  where  I  have  every  reason  to  believe  that  the  ova- 
ries were  also  inflamed,  there  was  great  mental  excitement,  and  tem- 
porary insanity  in  some. 


PELVIC   PERITONITIS.  625 

The  pain  in  the  pelvis  is  usually  acute,  much  more  so  than  in 
cellulitis,  and  there  is  great  tenderness  to  the  touch  ;  the  pelvic  ves- 
sels are  generally  affected,  and  there  is  marked  rectal  tenesmus,  and, 
if  the  peritonaeum  in  front  of  the  uterus  is  involved,  there  is  vesical 
tenesmus  also ;  in  fact,  this  vesical  irritation  is  often  an  exceedingly 
annoying  symptom. 

The  physical  signs  obtained  by  a  vaginal  examination  during  the 
first  stage  simply  reveal  tenderness  with  some  apparent  thickening 
of  the  roof  of  the  pelvis.  This  may  be  limited  to  one  portion  of  the 
pelvis,  but  in  well-marked  cases  it  extends  throughout.  When  exu- 
dation has  taken  place,  complete  fixation  of  the  uterus  is  found, 
and  the  roof  of  the  pelvis,  as  felt  through  the  vagina,  presents  the 
extreme  hardness  which  is  characteristic  of  peritonitis,  and  has  been 
called  the  dealboard  hardness  by  some.  If  nmch  lymph  is  thrown 
out,  especially  if  it  is  associated  with  considerable  serum,  a  mass  will 
be  found  behind  the  uterus  occupying  the  sac  of  Douglas.  At  no 
time,  however,  do  the  products  of  this  form  of  inflammation  extend 
above  the  superior  strait,  unless  as  an  exceedingly  rare  exception  ; 
in  case  that  the  disease  goes  on  to  the  formation  of  pus,  a  well-de- 
fined tumor  may  be  found  in  the  sac  of  Douglas,  and  if  this  pus  is 
discharged,  the  intense  hardness  at  that  point  may  disappear  in  part ; 
but  if  the  entire  exudation  is  lymph,  it  remains  hard  for  a  long 
time.  There  is  almost  always  a  displacement  of  the  uterus  as  well 
as  a  marked  fixation,  and  this  fixation  is  likely  to  remain  also ;  as 
contractions  occur  subsequently  the  position  of  the  uterus  may  be- 
come changed,  and  not  only  is  the  organ  thus  displaced,  but  it  is 
fixed  in  this  position. 

The  difference  between  the  physical  signs  of  pelvic  peritonitis 
and  other  diseases  of  the  pelvic  organs,  such  as  cellulitis  and  pelvic 
hsematocele,  will  be  given  in  treating  of  the  signs  of  the  latter. 

Treatment. — The  objects  to  be  attained  in  the  treatment  of  pel- 
vic peritonitis,  are  first,  to  control  or  limit  the  inflammation  so  far 
as  possible,  and  to  relieve  the  pain  which  is  usually  very  great ;  by 
accomplishing  the  latter,  we  do  all  that  is  possible  to  effect  the 
former,  the  means  employed  to  relieve  pain,  fortunately,  having  the 
greatest  control  over  the  inflammation.  The  great  remedy  then  in 
the  earliest  stages  of  pelvic  peritonitis,  is  opium ;  Alonzo  Clark  was 
the  first  to  discover  the  value  of  this  agent  in  general  peritonitis, 
and  to  him  we  owe  most  of  our  knowledge  of  the  management  of 
this  affection,  and  it  is  equally  available  (that  is,  the  opium  treatment) 
in  pelvic  peritonitis. 

The  quantity  of  opium  to  be  given  should  be  measured  by  the 
4] 


626  DISEASES  OF  WOMEN. 

effect  obtained ;  the  pain  should  be  relieved  and  kept  in  abeyance 
by  the  regular  administration  of  doses  sufficient  to  accomplish  this 
object ;  when  it  is  possible,  opium  or  morphine  should  be  given  by 
the  mouth,  because  in  this  way  the  patient  can  be  kept  more  uni- 
formly under  its  influence ;  it  often  happens,  however,  that  the 
stomach  is  too  irritable  to  retain  it  at  the  outset ;  the  morphine 
should  then  be  given  hypodermically  until  the  stomach  is  quiet.  In 
some  cases  where  there  is  marked  pelvic  tenesmus,  the  opium  may  be 
given  by  the  rectum ;  it  should  then  be  given  in  solution  or  enema, 
because  if  administered  in  suppositories  it  is  too  slightly  absorbed. 

Sometimes  in  giving  the  opium  in  this  way  it  will  aggravate  in- 
stead of  relieving  the  pelvic  tenesmus,  which  is  often  an  exceedingly 
annoying  symptom.  In  many  cases  the  patient  has  a  constant  de- 
sire to  urinate,  but  all  efforts  to  do  so  only  increase  greatly  the  suf- 
fering ;  this  induces  the  patient  to  resist  the  desire,  so  that  there  is 
a  vesical  tenesmus  with  retention  ;  under  these  circumstances  great 
relief  can  sometimes  be  given  by  the  careful  use  of  the  catheter. 
"Warm  applications  may  be  made  to  the  abdomen  in  the  form  of 
fomentations  ;  counter-irritation,  also,  is  often  useful,  which  may  be 
obtained  by  the  use  of  mustard-pastes,  turpentine  stupes,  etc. 

The  bowels  should  be  kept  quiet  for  a  few  days  by  the  use 
of  opium  until  the  acute  stage  has  passed,  when  they  should  be 
relieved  by  the  mildest  possible  means.  If  the  patient  is  seen  at 
the  very  onset  of  the  attack,  and  the  rectum  is  found  to  be  dis- 
tended, it  should  be  emptied  at  once  by  enema ;  during  the  early 
part  of  the  first  stagfe,  if  the  stomach  is,  as  it  usually  is,  very  irrita- 
ble, but  little  will  be  accomplished  in  the  way  of  giving  nourish- 
ment ;  the  thirst  may  be  alleviated  by  giving  ice  or  minute 
quantities  of  effervescing  waters.  If  there  is  great  prostration,  a 
little  champagne  and  Apollinaris  water  or  carbonic  water  may  be 
given  to  relieve  the  thirst  and  sustain  the  patient.  As  soon  as  the 
stomach  will  admit  of  it,  nourishing  food,  mostly  fluid,  should  be 
given ;  the  beef-extracts,  digested  milk,  and  gruel  will  usually  an- 
swer the  best  purpose.  At  the  end  of  the  acute  stage,  when  the 
pain  is  subsiding  or  relieved,  and  the  temperature  and  pulse  are 
down,  then  the  opium  can  be  greatly  reduced  in  quantity,  or  given 
up  entirely  if  the  patient  sleeps  well ;  usually,  however,  small  doses 
will  l)e  required  at  night  to  secure  rest. 

The  next  object  in  the  treatment  is  to  favor  a  further  limitation 
of  the  plastic  exudation,  and  to  promote  the  absorption  of  the  in- 
flammatory products ;  this  can  be  accomplished,  if  at  all,  by  the  use 
of  counter-irritation.    Small  blisters  applied  in  the  iliac  regions,  and 


PELVIC   PERITONITIS.  627 

repeated,  often  give  the  patient  relief  from  disturbance,  and  appar- 
ently favor  the  absorption  of  the  inflammatory  products.  The  best 
method  of  employing  blisters  under  these  circumstances  is  to  apply 
two,  one  on  each  side,  to  be  kept  there  until  the  skin  is  thoroughly 
vesicated,  then  puncture  the  vesicle  and  let  out  all  the  serum  and 
allow  the  cuticle  to  fall  down  upon  the  cutis,  and  then  apply  over 
this  absorbent  cotton,  and  allow  it  to  remain  undisturbed  until  heal- 
ing is  complete,  which  usually  takes  place  in  from  two  to  four  days ; 
blisters  may  again  be  applied  in  the  same  way.  During  this  time 
the  patient  should  be  sustained  by  nourishment  and  tonics,  quinine 
being  one  of  the  most  reliable  agents.  When  all  acute  symptoms 
have  subsided  and  there  is  no  evidence  of  any  serum  or  pus  accu- 
mulated in  the  pelvis,  the  further  disposition  of  the  inflammatory 
products  may  be  favored  by  the  use  of  iodine.  The  tincture  of 
iodine  may  be  applied  through  the  speculum  to  the  roof  of  the  pel- 
vis, that  is  around  the  cervix  uteri  and  upper  part  of  the  vagina, 
and  iodide  of  iron  may  be  given  internally.  Counter-irritants  from 
time  to  time  should  be  continued,  one  part  of  croton-oil  dissolved 
in  two  parts  of  sulphuric  ether  to  which  are  added  three  parts  of 
tincture  of  iodine,  makes  a  good  application  for  keeping  up  continu- 
ous irritation ;  this  should  be  painted  over  the  lower  portion  of  the 
abdomen,  and  repeated  when  the  fine  eruption  which  it  produces 
has  disappeared. 

These  remedies  should  be  changed  after  a  time  to  the  iodide  of 
potassium  or  the  bichloride  of  mercury  with  chloride  of  iron,  the 
latter  being  the  most  valuable  as  a  tonic  and  alterative.  While  there 
are  still  some  of  the  products  of  inflammation  remaining  in  the  pel- 
vis, or  at  least  for  a  long  time  after  the  subsidence  of  the  acute  in- 
flammatory symptoms,  the  greatest  possible  care  should  be  taken  to 
guard  the  patient  against  undue  labor  ;  standing,  walking,  or  riding 
may  produce  a  relapse,  and  hence,  the  patient  should  be  made  to 
carefully  feel  her  way  in  sitting  up  and  in  taking  exercise  ;  especially 
should  this  care  be  insisted  upon  at  the  menstrual  periods.  No 
rules  can  be  laid  down  with  reference  to  this  except  that  any  exer- 
cise which  excites  pain  should  be  avoided ;  short  stages  of  exercise, 
followed  by  rest  in  the  recumbent  position,  should  be  adhered  to,  a 
little  more  liberty  being  given  every  day,  in  case  it  does  not  pro- 
duce pain. 

All  exercise  of  the  sexual  functions  should  be  prohibited  until 
pain  and  tenderness  have  subsided.  In  case  there  is  an  accumula- 
tion of  serum  or  pus  in  the  sac  of  Douglas,  this  should  be  removed 
by  aspiration  ;  if  pus  is  found,  the  cavity  should  be  washed  out 


628  DISEASES  OF  WOMEN. 

with  a  weak  solution  of  carbolic  acid  and  water,  or  of  bichloride  of 
mercui'y,  and  if  this  does  not  relieve  the  pain,  an  opening  may  be 
made  and  drainage  established,  but  this  is  usually  unnecessary. 

ILLUSTRATIVE    CASES. 

A  Typical  Case  of  Uncomplicated  Pelvic  Peritonitis. — A  lady 
twenty-hve  years  of  age,  who  had  been  married  for  two  years,  and 
was  sterile,  began  to  menstruate  first  at  fifteen,  and  had  also  had 
dysmenorrho?a  slightly  for  the  first  years  of  her  adult  life,  but  it  was 
much  aggravated  after  her  marriage.  She  was  subject  to  attacks 
of  pelvic  pain,  though  not  severe,  after  much  exercise.  At  the  time 
of  the  attack  now  under  consideration,  she  was  menstruating,  and 
went  out  into  company,  and,  I  believe,  engaged  in  dancing,  and 
took  cold  on  her  way  home.  In  the  night  she  was  seized  with  vio- 
lent pain  in  the  pelvic  region,  with  nausea  and  vomiting.  She  was 
seen  early  in  the  morning,  and  her  temperature  was  found  to  be 
102°  F.,  and  her  pulse  120 ;  it  was  also  observed  that  she  was  a 
feeble-looking  person  of  a  tubercular  diathesis  ;  there  was  much  ten- 
derness to  the  touch  in  the  lower  portion  of  the  abdomen,  and  also 
considerable  tympanitic  distention.  On  digital  examination,  there 
was  evidently  an  increase  in  temperature,  with  congestion  and 
marked  tenderness  in  the  region  of  both  broad  ligaments  and  beiiind 
the  uterus.  There  was  no  fixation  apparent  nor  hardening  of  the 
tissues,  but,  owing  to  the  increased  tenderness,  it  was  difficult  to 
make  a  very  critical  examination.  The  rectum  was  distended  with 
fecal  matter.  A  hypodermic  injection,  consisting  of  ten  minims  of 
Magendie's  solution  of  morphia,  was  given,  and  warm  water  was 
injected  into  the  rectum ;  the  immediate  effect  of  the  enema  and 
evacuation  was  to  increase  the  pain,  and  in  two  hours  afterward  it 
was  necessary  to  give  five  more  minims  of  Magendie's  solution  hy- 
podermically ;  this  gave  considerable  relief,  Init  it  did  not  produce 
sleep.  In  the  middle  of  the  day  she  was  found  to  be  still  restless, 
with  an  anxious  and  somewhat  pinched  expression,  and  expressed 
herself  as  fearful  of  some  dangerous  trouble.  Another  hypodermic 
injection  was  given,  because  she  still  had  nausea,  but  no  vomit- 
ing ;  late  in  the  evening  she  was  still  in  much  pain,  having  come 
partially  out  from  under  the  influence  of  the  opium ;  she  was  still 
nauseated,  and  lier  temperature  was  103A°  F.,  and  her  pulse  over 
120;  she  complained  of  some  headache,  felt  hot  and  feverish,  and 
yet  she  was  in  a  perspiration.  Fifteen  more  minims  of  Magendie's 
solution  was  given,  which  secured  for  her  several  hours'  sleep. 
Early  in  the  morning  she  was  found  wakeful  and  restless,  and  the 


PELVIC  PERITONITIS.  629 

pain  had  returned ;  her  stomach  still  being  irritable,  another  ten 
minims  of  Magendie's  solution  of  morphia  were  given ;  during  the 
night,  while  awake,  small  pieces  of  ice  were  given,  which  were  grate- 
ful to  her,  but  she  was  still  thirsty,  and  begged  for  a  large  drink 
of  cold  water.;  she  was  given  half  a  wine-glass  of  cold  Vichy  every 
half-hour  when  she  desired  it ;  she  retained  some  of  this,  and  in  the 
forenoon  took  a  little  clear  coffee,  which  she  relished  and  retained. 
She  still  continued  to  suffer  from  nausea,  great  abdominal  tender- 
ness, and  considerable  pelvic  pain  ;  she  also  complained  of  a  very 
urgent  desire  to  urinate,  but  any  effort  to  do  so  gave  her  so  much 
pain  that  she  resisted  the  desire  ;  the  nurse  was  directed  to  pass  the 
catheter,  which  she  did,  and  drew  off  less  than  half  a  pint  of  urine 
of  a  remarkably  dark  color.  At  night  she  again  had  fifteen  minims 
of  the  solution  of  morphia,  which  gave  her  a  few  hours'  sleep,  when 
she  again  awoke  with  pain  ;  ten  minims  was  then  given,  which  car- 
ried her  through  the  night  fairly  comfortable. 

On  the  third  day  after  the  attack,  upon  digital  examination,  the 
parts  of  the  portion  of  the  pelvis  within  reach  were  found  to  be  hard, 
and  the  uterus  fixed.  The  hardness  and  fixation  extended  entirely 
across  and  behind  the  broad  ligament  and  the  uterus ;  a  diagnosis  of 
pelvic  peritonitis  was  then  made  without  hesitation.  The  nausea  at 
this  time  was  less  marked,  so  that  she  retained  the  Yichy- water  and 
coffee  and  tea,  and  occasionally  a  little  beef-tea ;  but  these  were  ad- 
ministered in  small  doses,  care  being  taken  not  to  give  her  the  Vichy 
immediately  before  or  after  she  took  any  of  the  others. 

Every  little  change  in  the  temperature  was  observed  at  this  time. 
It  had  required  from  forty-five  to  fifty  minims  of  Magendie's  solu- 
tion to  keep  her  comfortable  during  the  twenty -four  hours  up  to  the 
end  of  the  third  day  ;  after  that  the  opium  was  given  by  the  mouth, 
twenty  minims  of  Squibb's  liquor  opii  comp.  were  given  every  three, 
four,  or  six  hours,  according  to  the  disturbance  or  pain  which  she 
had,  and  from  twenty-five  to  thirty  minims  at  bed-time.  This  was 
sufficient  to  keep  her  tolerably  comfortable,  and  to  secure  a  sufiicient 
amount  of  sleep  in  the  night  and  an  occasional  nap  during  the  day. 
About  this  time  she  suffered  very  much  from  tympanitic  distention  ; 
occasionally  she  could  raise  gas  from  the  stomach,  but  this  gave  her 
very  little  relief.  On  the  fifth  day  six  grains  of  quinine,  dissolved 
in  sulphuric  acid,  and  added  to  an  ounce  of  sirup  of  acaCia  and  a 
little  warm  water,  was  given  by  enema ;  this  was  retained,  and  pro- 
duced partial  relief  from  tympanitic  distention. 

About  a  week  from  the  time  of  the  attack  the  pelvic  peritonaeum 
was  evidently  covered  with  a  marked  exudation,  especially  that  por- 


630  DISEASES  OF  WOMEN. 

tion  forming  the  sac  of  Douglas,  while  the  fixation  and  induration 
involved  the  entire  roof  of  the  pelvis ;  it  was  most  marked  behind 
the  uterus,  extending  down  to  a  point  on  a  level  of  the  surface  of 
the  cervix  uteri. 

On  about  the  eighth  day  a  marked  improvement  had  taken  place 
in  lier  general  condition;  the  temperature  was  101|-°  F.,  and  the 
pulse  a  little  above  100  ;  her  tongue  was  still  thickly  coated,  but  was 
beginning  to  clean  off  on  the  end  and  sides ;  the  nausea  had  mostly 
subsided,  but  she  had  no  appetite ;  she  was  able,  however,  to  take 
a  fair  amount  of  fluid  nourishment — beef -extract,  digested  gruel,  and 
milk,  with  a  little  tea  and  coffee  from  time  to  time ;  she  still  had 
thirst,  and  took  considerable  water.  We  were  able  at  this  time  to 
reduce  the  quantity  of  liquor  opii  comp.  about  five  drops  every  three 
or  four  hours,  with  twenty-five  drops  at  bed-time.  At  this  time  we 
began  the  use  of  small  blisters,  and  continued  to  keep  the  lower  por- 
tion of  the  abdomen  in  a  state  of  irritation  for  the  next  ten  or  twelve 
days ;  she  was  also  given  a  pill  three  times  a  day,  composed  of  one 
grain  of  quinine,  one  tenth  of  a  grain  of  extract  of  belladonna,  one 
half  grain  of  comp.  extract  of  colocynth,  and  one  fourth  grain  of 
ipecac  ;  this,  after  a  couple  of  days,  excited  some  peristaltic  action  of 
the  bowels,  and,  after  an  enema  of  soap-suds,  the  bowels  moved.  This 
relieved  the  tympanitis  considerably,  and,  although  she  felt  greatly 
distressed  immediately  after  the  movement  of  the  bowels,  she  was 
apparently  better  for  it. 

All  this  time  she  had  a  good  deal  of  irritation  of  the  rectum  and 
bladder,  and  a  constant  sense  of  fullness  and  distress  in  the  pelvis, 
with  pain  that  varied  very  much  in  severity.  From  this  onward 
she  suffered  very  little,  althougli  obliged  to  keep  quiet  in  bed  ;  she 
continued  to  take  a  fair  amount  of  nourishment  and  solid  food,  such 
as  rare  steak  and  a  chop,  which  with  toast  and  milk,  were  added  to 
her  bill  of  fare. 

The  quantity  of  opium  was  diminished  until  she  only  took  one 
dose  at  bed-time ;  the  pills  were  continued,  and  the  bowels  moved 
every  third  day  by  enema ;  the  temperature  had  now  come  down  to 
100°  F.,  and  the  pulse  to  95,  but  there  was  still  very  little  apparent 
difference  in  the  condition  of  the  jielvis.  This  line  of  treatment, 
including  the  counter-irritation,  was  continued  until  the  end  of  the 
third  week ;  at  that  time  she  was  permitted  to  sit  up  a  little  in  bed, 
and  was  able  to  turn  from  side  to  side  without  much  discomfort. 
She  continued  in  this  way  for  three  days  longer,  when  the  pain 
began  again,  and  the  pulse  and  temperature  ran  up ;  her  stomach 
became  again  disturbed,  although  there  was  no  vomiting,  and  the 


PELVIC   PERITONITIS.  631 

opiarn  had  to  be  given  in  small  doses  more  frequently,  in  order  to 
relieve  her — in  short,  there  was  every  appearance  of  a  lighting  up 
of  the  acute  trouble,  but  the  temperature  did  not  go  beyond  101°  F., 
or  the  pulse  beyond  110,  and  she  was  exceedingly  irritable,  nervous, 
and  despondent  at  this  time ;  the  menstruation  then  came  on,  and 
after  a  day  her  pain  began  to  subside  a  little,  and  at  the  end  of  the 
third  day  her  condition  was  about  what  it  was  before  the  relapse 
took  place.  This  undoubtedly  was  simply  a  dysmenorrhcEa  from  a 
lighting  up  of  the  inflammation. 

After  the  menstrual  flow  subsided,  she  improved  in  her  general 
condition  very  decidedly,  and,  at  the  end  of  the  fifth  week  from  the 
beginning  of  the  attack,  she  was  able  to  sit  up  a  little  while  in  bed, 
and  to  be  occasionally  lifted  into  her  reclining-chair.  Her  tempera- 
ture and  pulse  were  nearly  normal,  but  she  was  quite  weak,  and  still 
had  some  disturbance  in  the  region  of  the  pelvis ;  milder  forms  of 
counter-irritants  were  employed,  occasionally  using  a  mild  mustard- 
paste,  and  sometimes  painting  with  the  tincture  of  iodine ;  she  was 
then  put  under  general  tonic  treatment,  including  quinine  and 
iron. 

The  bowels  were  kept  regular  by  the  pills  which  were  prescribed 
before.  At  this  time  there  was  still  marked  fixation  and  induration 
in  the  location  of  the  pelvic  peritonaeum,  and  from  this  onward  the 
treatment  consisted  in  good,  generous  nourishment,  wine,  and  tonics ; 
the  iodide  of  iron  alternated  with  bichloride  of  mercury  and  chloride 
of  iron  was  continued  off  and  on  for  about  six  months ;  at  the  end 
of  that  time  her  health  was  about  as  good  as  it  was  before  she  was 
taken  ill,  although  she  suffered  more  from  her  dysmenorrhcea  than 
formerly,  and  was  obliged  to  keep  in  bed  during  the  menstrual 
period.  About  this  time  an  examination  was  made  when  the  indura- 
tion had  partly  disappeared,  but  not  wholly ;  there  was  still  fixation 
of  the  uterus,  and  efforts  were  now  made  to  relieve  her  dysmenor- 
rhoea,  which  was  evidently  due  to  an  anteflexion  of  the  body  of  the 
uterus,  by  enlarging  the  canal  by  gradual  dilatation  ;  the  first  at- 
tempt at  this,  however,  gave  rise  to  so  much  pain  and  suffering  that 
no  further  efforts  were  made  in  that  direction  at  that  time.  A  vag- 
inal douche  of  hot  water  was  ordered,  but  that  did  not  give  her 
any  apparent  relief,  nor  did  it  appear  to  influence  the  disposition  of 
the  inflammatory  products.  Tincture  of  iodine  was  applied  around 
the  cervix  uteri  and  upper  portion  of  the  vagina  once  a  week  for  a 
month  or  two,  and  this  appeared  to  be  beneficial ;  at  least  she  im- 
proved while  this  was  being  employed,  but  I  presume  that  the  con- 
stitutional medication  had  most  to  do  with  her  progress — in  fact,  my 


632  DISEASES  OP  WOMEN. 

experience  with  this  ease  and  many  others  has  satisfied  me  that  local 
treatment  in  old  cases  of  pelv^ic  peritonitis  does  harm  ten  times  to 
once  that  it  does  good.  She  was  kept  upon  her  general  tonic  and 
alterative  course  of  treatment  for  six  months  after  suspending  all 
local  treatment,  and  then  it  was  found  that  there  was  a  marked  im- 
provement in  the  local  condition  ;  as  soon  as  the  slight  mobility  of 
the  uterus  was  established,  the  induration  and  fixation  much  more 
rapidly  diminished. 

The  patient  passed  from  under  my  observation,  but  returned 
again  in  two  years  to  be  treated  for  dysmenorrhea,  and  I  then  had 
an  opportunity  of  examining  her  carefully,  and  found  considerable 
mobility  of  the  uterus,  and  also  of  the  broad  ligament ;  the  marked 
induration  had  wholly  disappeared — in  fact,  the  only  trace  of  her 
former  peritonitis  remaining  was  a  small  mass  in  the  most  dependent 
part  of  the  sac  of  Douglas ;  this  did  not  appear  to  give  her  any 
trouble ;  there  was  also  less  anteflexion  of  the  body  of  the  uterus. 
I  was  then  able  to  treat  her  for  her  dysmenorrhoea,  and  succeeded 
in  relieving  her  to  some  extent,  but  not  wholly.  Four  years  after 
I  heard  of  this  patient,  and  she  had  still  maintained  fair  health,  but 
suffered  slightly  at  her  menstrual  periods. 

A  Case  of  Circumscribed  Pelvic  Peritonitis  of  the  Mildest  Charac- 
ter.— A  young  lady  of  somewhat  delicate  organization,  who  had  suf- 
fered from  irregular  and  painful  menstruation,  was  seized  about  the 
time  of  one  of  her  periods  with  violent  pain  in  the  left  ovarian  re- 
gion ;  she  was  out  at  the  time  the  pain  came  on,  and  I  believe  was 
overfatigued ;  she  returned  home  and  went  to  bed,  and  I  saw  her 
several  hours  afterward ;  she  then  had  tenderness  on  deep  pressure 
in  the  left  iliac  region  and  also  had  pain  there  of  an  acute  character. 
Her  temperature  was  below  100°  F.,  but  her  pulse  was  over  100  ;  she 
was  somewhat  nervous  and  restless ;  I  gave  her  a  dose  of  bromide  of 
sodium  with  a  few  minims  of  liquor  opii  comp.,  and  ordered  it  to  be 
repeated  during  the  night  if  she  did  not  sleep. 

One  more  dose  was  necessary  to  give  her  a  comfortable  night, 
and  in  the  morning  when  I  saw  her  there  was  no  constitutional  dis- 
turbance except  a  loss  of  appetite  and  some  flatulence  ;  her  pulse 
was  a  little  rapid  and  there  was  still  pain  and  tenderness,  but  not 
marked,  in  the  left  side.  In  the  evening  of  that  day  her  menstrual 
flow  began  and  continued  normally  though  more  free  than  usual ;  this 
improved  her  condition  somewhat,  and  although  she  continued  in 
bed  for  about  a  week  on  account  of  the  return  of  pain  upon  trying 
to  sit  u]),  still  she  made  a  good  recovery,  and  was  around  as  usual 
the  week  following.     For  a  number  of  weeks  she  had  occasional  at- 


PELVIC  PERITONITIS.  f533 

tacks  of  pain  and  tenderness  on  that  side,  especially  at  her  men- 
strual periods. 

This  attack  passed  off,  and  she  was  in  fair  health  until  three 
years  afterward,  when  from  exposure  she  contracted  double  pneu- 
monia, of  which  she  died.  The  physician  who  attended  her  at  that 
time  obtained  a  post-mortem  examination,  and,  knowing  that  she  had 
been  a  patient  of  mine  at  former  times,  invited  me  to  be  present ; 
nothing  of  interest  being  found  in  the  thorax  I  suggested  the  pro- 
priety of  examining  the  pelvic  viscera  in  the  hope  of  determining 
the  pathological  conditions  which  gave  rise  to  her  irregular  and 
somewhat  painful  menstruation.  I  had  at  this  time  entirely  forgot- 
ten the  attack  above  described,  and  only  remembered  it  when  we 
found  the  products  of  the  pelvic  peritonitis  on  the  left  broad  liga- 
ment. The  fimbriated  extremities  of  the  Fallopian  tube  were 
matted  together  by  the  old  exudate,  and  the  peritonseum  covering 
the  outer  portion  of  the  tube  and  extending  downward  showed  evi- 
dence of  an  old  inflammation ;  the  ovary,  however,  did  not  appear  to 
be  affected,  except  that  two  or  three  fimbriae  of  the  tube  were  ad- 
herent to  it.  This  case  illustrates  the  circumscribed  mild  form  of 
pelvic  peritonitis  which  occurs  quite  frequently  no  doubt,  but  is 
overlooked,  except  when  found  at  post-mortem. 

Septic  Peritonitis  Terminating  Fatally. — This  case  illustrates  the 
other  extreme  from  the  one  just  related.  A  strong,  healthy  servant- 
girl  had  leave  of  absence  on  Saturday,  and  staying  out  too  late, 
tried  to  save  time  by  crossing  a  field  instead  of  taking  the  road 
home ;  and  upon  jumping  a  fence  near  the  house,  she  was  sud- 
denly seized  with  the  most  violent  pain  in  the  pelvis ;  she  reached 
home  with  great  difliculty,  and  was  helped  to  bed  by  her  fellow-serv- 
ants ;  nausea,  and  vomiting  came  on,  and  she  became  pale,  faint,  and 
covered  with  cold,  clammy  perspiration ;  the  physician  of  the  fam- 
ily, Dr.  Woodruff,  was  sent  for  in  the  night,  and  by  the  judi- 
cious use  of  morphine  hypodermically  and  stimulants  administered 
by  the  rectum,  he  succeeded  in  bringing  her  out  of  her  state  of  par- 
tial collapse.  Her  tempera tui'e  then  rapidly  ran  up  to  105°  F.,  and 
her  pulse  to  130  ;  there  was  extreme  tenderness  of  the  abdomen 
and  distention ;  the  vomiting  continued  so  persistently  that  it  was 
impossible  to  administer  nourishment  or  medicine  by  the  mouth. 
The  physician  made  a  diagnosis  of  peritonitis  which  he  believed  to 
be  general,  and  I  saw  her  with  him  in  the  morning  and,  concurring 
in  his  diagnosis,  we  continued  the  use  of  opium,  but  her  pulse  had 
improved  and  the  stimulants  were  suspended.  The  temperature  and 
pulse  continued  very  high  and  her  general  appearance  was  more  like 


634  DISEASES  OF   WOMEN. 

that  of  a  case  of  puerperal  peritonitis  than  any  other,  but  there  was 
still  some  hope  entertained  of  saving  her  until  Tuesday  afternoon 
when  she  began  to  vomit  that  greenish  material  so  often  seen  in  gen- 
eral peritonitis. 

Her  pulse  became  feeble  and  very  rapid ;  her  temperature  in 
the  vagina  ran  up  to  106°  F.,  and  she  appeared  like  one  passing  into 
a  state  of  collapse.  She  became  more  and  more  depressed,  and  died 
of  shock  on  Wednesday  morning.  The  case  being  somewhat  un- 
usual, a  grave  question  was  raised  as  to  the  causation  ;  and  hence  a 
most  careful  post-mortem  examination  was  made. 

On  opening  the  abdomen  we  found  that  a  few  coils  of  the  small 
intestine  had  dipped  into  the  upper  part  of  the  pelvis,  and  were  ad- 
herent by  recent  soft  exudate  to  the  U23per  part  of  the  uterus.  The 
sac  of  Douglas  was  found  nearly  full  of  pus,  and  the  whole  pelvic 
peritonaeum  was  covered  with  the  products  of  acute  inflammation. 
On  carefully  removing  the  pus  and  some  soft  lymph  from  the  sac  of 
Douglas  and  broad  ligaments,  a  recent  opening  was  found  in  one  of 
the  ovaries  which  led  to  a  cyst  not  larger  than  a  hazel-nut ;  in  this 
cyst  were  found  a  few  drops  of  brownish-looking  fluid  which  was 
preserved  for  microscopical  examination. 

The  general  peritonasum,  except  that  covering  the  intestine 
which  rested  upon  the  uterus,  was  perfectly  normal.  Nothing  else 
abnormal  was  found  in  any  of  the  organs  of  the  body ;  the  heart 
was  rather  below  the  average  size,  and  so  were  the  blood-vessels ; 
beyond  this  all  was  normal. 

It  is  clearly  evident  that  this  girl  had  small  ovarian  cysts,  the 
contents  of  which  were  highly  septic,  and  when  the  rupture  occurred 
this  fluid  set  up  peritonitis,  which  being  highly  septic  in  character, 
developed  the  violent  attack  which  overwhelmed  the  patient's  nerv- 
ous system. 

A  Case  of  Pelvic  Peritonitis  caused  by  Gonorrhoea,  and  followed  by 
Pyosalpinx. — This  lady  was  twenty-six  years  of  age,  and  had  always 
enjoyed  very  good  health  until  she  Avas  married.  Two  years  after 
her  marriage  she  was  suddenly  taken  with  acute  vaginitis  and  ure- 
thritis ;  she  then  came  under  my  care,  and  I  then  made  a  diagnosis 
of  gonorrha3a  and  subsequently  procured  unmistakable  evidence  from 
her  husband  that  such  was  the  nature  of  the  attack. 

The  vaginitis  and  urethritis  yielded  promptly  to  treatment,  and 
she  was  dismissed  apparently  well,  but  returned  to  state  that  she  still 
suffered  from  uterine  leucorrlKjea ;  1  then  found  a  well-marked  cerv- 
ical endometritis  with  some  remaining  vaginitis  of  the  upper  portion 
of  the  vagina.    While  she  was  under  treatment  for  this  she  suddenly 


PELVIC   PERITONITIS.  635 

developed  a  pelvic  peritonitis,  wliich  was  not  especially  severe  but  in 
which  there  was  considerable  exudation,  as  indicated  by  the  fixation 
and  induration  of  the  pelvic  organs.  Under  ordinary  treatment  she 
progressed  fairly  well,  but  the  case  was  unusually  tedious.  At  the 
end  of  the  year  1  considered  her  well,  but  she  still  had  some  pelvic 
pain  occasionally,  although  the  products  of  the  inflammation  had 
been  almost  entirely  disposed  of,  so  that  there  was  mobility  of  the 
pelvic  viscera  and  very  little  hardening  of  the  parts  except  in  the 
sac  of  Douglas  where  there  still  remained  some  of  the  old  exudate 
which  presented  a  somewhat  irregular,  nodulated  condition  to  the 
touch.  At  this  time  she  was  again  taken  ill  with  the  symptoms  of 
another  attack  of  pelvic  peritonitis ;  the  pain  and  tenderness  on  this 
occasion,  however,  were  limited  to  the  left  side,  and  a  tumor  was 
soon  developed  which  was  elastic  to  the  touch ;  this  led  me  to  sus- 
pect that  this  was  a  case  of  saljDingitis  instead  of  peritonitis,  and 
when  the  acute  symptoms  subsided  somewhat,  I  endeavored  to  con- 
firm my  suspicions  by  aspirating  the  tumor ;  I  found  pus  and  was 
able  to  draw  off  about  an  ounce  and  a  half  of  it ;  the  sac  soon  filled 
up  again,  and  she  suffered  a  great  deal  of  -psiin  and  constitutional 
disturbance,  evidently  due  to  a  slight  septicaemia. 

As  the  case  was  one  of  long  duration,  she  became  discouraged 
with  my  treatment  at  this  time,  and  on  the  advice  of  friends,  went 
to  the  hospital.  I  learned  afterward,  that  while  in  the  hospital  she 
was  operated  upon,  the  distended  tube  being  removed  after  the 
manner  of  Lawson  Tait. 

A  Case  of  Pelvic  Peritonitis,  followed  by  Permanent  Displacement 
of  the  Uterus,  Dysmenorrhoea,  and  Cystitis. — This  was  a  married  lady, 
about  twenty-nine  years  of  age,  who  had  suffered  most  of  the  time 
from  dysmenorrhoea  and  sterility,  caused  by  anteflexion  of  the  body 
of  the  uterus  with  slight  retroversion.  During  the  treatment  for 
this  malformation  of  the  uterus  she  was  attacked  with  pelvic  peri- 
tonitis, the  exciting  cause  being  a  rather  forcible  effort  to  correct 
the  retroversion.  The  pelvic  peritonitis  ran  its  ordinary  course,  and 
terminated  in  recovery ;  but  afterward  the  uterus  was  found  in  a 
markedly  retro  verted  condition,  and  bound  down  to  the  posterior 
wall  of  the  sac  of  Douglas ;  the  bladder  was  also  drawn  backward 
Avith  the  uterus,  and  held  in  that  position.  This  gave  rise  to  dys- 
menorrhoea quite  as  marked  as  that  from  which  she  suffered  before 
her  peritonitis.  The  malposition  of  the  bladder  caused  by  the  ad- 
hesions rendered  it  impossible  to  completely  empty  that  organ,  and 
the  partial  retention  of  the  urine  developed  a  very  troublesome 
cystitis. 


636  DISEASES  OP  WOMEN. 

All  efforts  to  restore  the  uterus  and  bladder  to  their  normal  po- 
sitions were  without  avail.  The  djsmenorrlioea  was  partly  relieved 
by  treating  tlie  cervical  endometritis,  which  she  also  had,  and  dilating 
the  internal  os  a  little.  The  cystitis  was  controlled  by  long-continued 
local  treatment,  but  she  still  suffered  from  some  pelvic  tenesmus, 
and,  in  fact,  remained  something  of  an  invalid  during  the  five  or 
six  years  that  she  remained  under  my  observation. 

Pelvic  Peritonitis,  which  went  on  to  Suppuration,  the  Pus  accumu- 
lating in  the  Sac  of  Douglas ;  treated  by  Aspiration ;  and  Recovery. — 
This  patient  was  a  lady  who  had  married  and  had  borne  two  chil- 
dren, became  a  widow,  and  married  a  second  time,  and  who  had 
contracted  gonorrhoea,  which  led  to  a  severe  attack  of  peritonitis. 
There  was  nothing  peculiar  in  the  clinical  history  of  the  case,  except 
that  it  was  very  severe,  but  she  progressed  fairly  well  up  to  the  time 
when  the  acute  symptoms  should  have  disappeared.  Her  tempera- 
ture and  pulse  continuing  high,  and  her  general  nutrition  showing 
evidence  of  some  septic  influence,  it  was  presumed  that  pus  had  been 
developed  somewhere  in  the  pelvis,  and,  as  there  was  a  large  tumor 
or  a  well-defined  mass  in  the  sac  of  Douglas,  the  aspirating-needle 
was  introduced  in  the  hope  of  finding  the  location  of  the  suppura- 
tion. 

Over  two  ounces  of  sero-purulent  fluid  were  drawn  off,  which 
improved  the  patient's  condition  almost  immediately ;  she  had  less 
pain  afterward,  her  pulse  and  temperature  improved,  and  her  gen- 
eral nutrition  also ;  this  improvement,  however,  was  only  for  a  short 
time,  when  the  former  symptoms  returned,  and  aspiration  was  again 
practiced  with  the  result  of  finding  a  small  quantity  of  pus.  The 
sac  was  at  the  same  time  washed  out  with  a  solution  of  bichloride 
of  mercury,  and  from  this  onward  she  did  well,  although  she  did 
not  fully  regain  her  original  health;  she  still  had  attacks  of  pelvic 
pain  at  times,  and  active  exercise  usually  brought  on  pelvic  tenes- 
mus. The  last  time  that  she  was  examined,  about  a  year  and  a  half 
from  the  time  of  the  pelvic  peritonitis,  there  was  still  considerable 
fixation  of  the  pelvic  organs  and  induration,  showing  that  the  prod- 
ucts of  the  bygone  inflammation  had  not  by  any  means  been  all  dis- 
posed of. 


CHAPTEE  XXXIY. 


PELVIC    H.EMATOCELE, 


Pelvic  hsematocele  is,  as  tlie  term  indicates,  an  accumnlation  of 
blood  in  the  pelvis,  or,  more  strictly  speaking,  in  the  sac  of  Douglas, 
or  else  in  the  cellular  tissues  of  the  pelvis.  Of  course,  the  accumu- 
lation of  blood  is  merely  the  result  of  some  other  lesion,  and  conse- 


FiG.  236. — Subperitoneal  pelvic  hgematocele.     U,  displaced  uterus  ;  B,  empty  bladder. 

quently  pelvic  hsematocele  is  secondary  to  the  lesion  which  gives 
rise  to  it.  It  is  produced  so  often  as  the  result  of  rupture  in  ectopic 
gestation  that  it  has  been  doubted  of  late  vrhether  it  ever  occurs 
under  any  other  circumstances. 

637 


638 


DISEASES  OF   WOMEN. 


There  are  two  forms  of  pelvic  hematocele,  distinguished  accord- 
ing  to  the  location  of  the  accumulation  of  blood :  subperitoneal 
pelvic  hfematocele,  or  that  in  which  the  haemorrhage  occurs  in  the 
cellular  tissues  (Fig.  236),  and  intra-peritoneal  hgematocele,  in  which 
the  blood  accumulation  is  in  the  pelvic  cavity — that  is,  in  the  sac  of 
Douglas  (Fig.  237). 

The  subperitoneal  variety  is  not  always  a  very  serious  affection, 
while  the  intra-peritoneal  variety  is  one  of  the  most  dangerous  dis- 
eases which  comes  under  the  observation  of  the  gynecologist ;  there- 


FiG.  237. — Intra-peritoneal  pelvic  hiematocele. 

fore  the  former  will  be  dismissed  with  a  few  remarks  later,  while  the 
most  of  what  follows  will  refer  to  the  intra-peritoneal  variety  wholly. 
The  sources  of  the  haemorrhage  giving  rise  to  this  affection 
which  have  so  far  been  accurately  determined  are  from  rupture  of 
blood-vessels  of  the  ovaries  or  veins  of  the  broad  ligaments,  and 
from  rupture  of  an  aneurism  of  some  of  the  pelvic  arteries,  reflux 
of  blood  from  the  uterus  or  Fallopian  tubes,  and  general  transuda- 
tion from  the  smaller  blood-vessels  in  certain  conditions  of  the  blood, 
such  as  that  of  purpura,  for  example.     Eupture  of  the  sac  in  cases 


PELVIC   HiEMATOCELE.  639 

of  extra-uterine  pregnancy  has  also  been  mentioned  as  a  source  of 
haemorrhage,  giving  rise  to  pelvic  hsematocele  ;  but  as  extra-uterine 
pregnancy  is  a  matter  wholly  by  itself,  it  need  not  be  considered  in 
this  connection.  It  will  be  seen  from  this  that  the  conditions  which 
give  rise  to  hi3emorrhage  may  all  be  classed  under  two  heads  :  first, 
some  condition  of  the  blood-vessels  which  favors  their  giving  way, 
and,  second,  the  conditions  of  the  blood  which  favor  haemorrhage, 
such  as  we  find  in  persons  of  the  haemorrhagic  diathesis. 

The  extent  of  the  accumulation  depends  somewhat  upon  the  size 
of  the  ruptured  vessels.  If  the  haemorrhage  is  extensive,  the  loss 
of  blood  and  shock  may  cause  a  fatal  termination  in  a  few  hours. 
This  shock  is  due  to  the  impression  made  upon  the  peritonaeum  by 
the  sudden  effusion  of  blood,  which  acts  as  a  foreign  body.  If  this 
does  not  occur,  and  the  haemorrhage  ceases,  then  pelvic  peritonitis — 
sometimes  general  peritonitis — supervenes,  and  the  products  of  the 
inflammation  are  thrown  around  the  blood-clot,  and  in  this  way  it 
becomes  walled  in.  If,  again,  the  patient  survives  the  acute  perito- 
nitis, the  serous  portion  of  the  blood  is  slowly  disposed  of  by  absorp- 
tion, and  in  time  the  solid  clot  softens  down,  and  is  also  disposed  of 
in  the  same  way  ;  and,  again,  the  patient  may  recover  with  the  pel- 
vic organs  damaged  by  the  inflammatory  products,  which  remain 
and  behave  very  much  as  in  simple  pelvic  peritonitis.  Occasionally, 
however,  it  happens  that,  in  place  of  the  blood-clot  being  disposed 
of  in  this  way,  it  breaks  down,  and  suppuration  "of  the  products  of 
the  peritonitis  occurs,  and  death  ensues  from  septicaemia. 

This,  then,  gives  three  well-defined  stages  in  the  progress  of  pelvic 
haeraatocele  :  First,  the  stage  of  haemorrhage  ;  second,  the  stage  of  pel- 
vic inflammation  ;  and,  third,  the  stage  in  which  the  clot  is  disposed 
of  by  absorption,  or  breaks  down,  and  gives  rise  to  suppuration. 

The  extent  of  pelvic  peritonitis,  and  the  subsequent  disposal  of 
the  clot,  or  the  degree  of  suppurative  action  which  may  take  place, 
depend  somewhat  upon  the  quantity  of  the  blood  accumulation,  and 
also  upon  the  patient's  general  condition  at  the  time,  and  the  char- 
acter of  the  blood.  In  case  the  patient  is  not  in  vigorous  health  at 
the  time  of  the  haemorrhage,  and  if  the  haemorrhage  is  great,  the 
shock  is  more  likely  to  prove  fatal ;  or,  if  that  does  not  take  place, 
then  the  extent  and  character  of  this  inflammation,  and  the  tendency 
to  decomposition  and  suppuration,  are  rendered  greater  in  case  the 
blood  is  in  any  way  abnormal. 

A  limited  quantity  of  normal  blood  in  the  sac  of  Douglas  does 
not  necessarily  give  rise  to  very  great  trouble,  but  we  can  readily 
suppose  that,  if  blood  is  abnormal,  as  in  the  case  of  scorbutus  or  pur- 


640  DISEASES   OF  WOMEN. 

pura,  then  it  is  more  likely  to  be  irritating,  and  hence  the  greater 
will  be  the  inflammation  and  tendency  to  suppuration.  Figs.  236 
and  237,  illustrate  the  two  varieties  of  pelvic  hsematocele,  classified 
according  to  location. 

Causation. — The  causes  of  pelvic  hsematocele  are  necessarily 
predisposing  and  exciting.  The  predisposing  causes  are  certain 
changes  in  the  blood-vessels  of  the  pelvis,  overdistention  of  the  ves- 
sels which  enfeebles  their  walls,  and  degeneration  of  the  walls  of  the 
blood-vessels,  which  renders  them  more  easily  ruptured  under  extra 
pressure.  Any  one  of  these  conditions  of  the  blood-vessels  may  be 
produced  by  continued  hypersemia  or,  more  especially,  engorgement. 
It  is  well  known  that  congestion  on  the  venous  side  of  the  circula- 
tion tends  to  degeneration  of  tissues  of  all  kinds,  and  the  walls  of 
the  blood-vessels  prove  no  exception.  Hence,  in  cases  of  long-con- 
tinued congestion  of  the  pelvic  organs  from  any  cause,  such  as  ob- 
struction of  the  portal  circulation,  imperfect  involution  after  par- 
turition, or  in  persons  whose  occupation  compels  their  continued 
standing  or  sitting,  the  strength  of  the  walls  becomes  impaired,  and 
they  are  liable  to  rupture.  On  the  other  hand,  in  certain  abnormal 
conditions  of  the  blood,  such  as  that  found  in  purpura  or  scorbutus, 
there  is  a  tendency  to  haemorrhage  from  the  small  vessels  under 
extra  pressure.  It  follows,  also,  that  the  predisposition  to  hoemor- 
rhage  will  be  most  marked  during  the  period  of  ovarian  activity, 
and  also  at  the  menstrual  period. 

The  exciting  causes  of  pelvic  haematocele  are,  in  a  word,  any- 
thing which  can  produce  overdistention  of  the  blood-vessels,  sudden 
checking  of  the  menstrual  flow,  maintaining  the  erect  position  for 
any  great  length  of  time,  violent  exercise  and  overexertion,  and  the 
like,  injuries  or  falls,  and  when  the  haemorrhage  comes  from  the 
Fallopian  tubes  or  the  uterus,  it  is  caused  by  some  obstruction  of  the 
cervical  canal  or  the  Fallopian  tubes. 

Symjytoinatology . — In  the  majority  of  patients  who  have  this 
affection  the  haemorrhage  is  often  preceded  by  symptoms  indica- 
tive of  some  pelvic  affection,  but  these  need  not  necessarily  be  suffi- 
ciently marked  to  call  the  attention  either  of  the  patient  or  the 
physician  to  them ;  so  it  may  be  said  that  the  symptoms  of  pelvic 
haematocele  are  developed  suddenly.  The  symptoms,  of  course, 
differ  as  the  disease  progresses,  each  stage  having  its  own  charac- 
teristic manifestations.  When  the  haemorrhage  occurs,  there  is  first 
severe  pain  in  the  pelvis,  followed  soon  after  by  all  the  evidences  of 
shock,  such  as  faintness,  coldness  of  the  extremities,  pallor,  and  cold, 
clammy  perspiration,  a  feeling  of  nausea,  and  sometimes  vomiting. 


PELVIC  HEMATOCELE.  641 

If  the  temperature  is  taken  at  this  time,  it  will  be  found  to  be  sub- 
normal, and  the  pulse  irregular  and  rapid,  although  sometimes  it  is 
slow  and  feeble. 

In  a  short  time  to  these  symptoms  are  added  well-marked  pelvic 
tenesmus,  including  vesical  and  rectal  tenesmus  and  tympanites.  If 
the  hasmorrhage  stops  and  the  patient  recovers  from  the  shock,  then 
inflammatory  symptoms  are  developed. 

These  constitutional  and  local  symptoms  are  exactly  the  same  as 
those  observed  in  peritonitis,  because  they  are  due  to  the  peritoneal 
inflammation  which  usually  starts  up  about  forty-eight  hours  after 
reaction  from  the  hsemorrhage.  If  the  patient  passes  through  the 
inflammatory  stage  and  the  blood  accumulation  is  disposed  of  by 
absorption,  the  symptoms  will  then  be  altered  to  a  modified  pelvic 
tenesmus  with  occasional  pain  of  a  mild  character  and  a  general 
malnutrition,  indicating  some  source  of  a  mild  form  of  septicaemia. 
On  the  other  hand,  if  suppuration  and  breaking  down  of  the  blood- 
clot  take  place,  the  constitutional  disturbances,  as  indicated  by  high 
temperature,  rapid  pulse,  and  deranged  nutrition,  will  show  the  sep- 
ticaemia which  usually  takes  place  under  those  circumstances. 

Physical  Signs. — In  the  stage  of  haemorrhage  there  are  simply 
tenderness  and  distention  of  the  sac  of  Douglas,  indicated  by  a  mass 
which  fluctuates  on  pressure  ;  the  tumor  is  soft,  smooth,  and  uniform. 

After  coagulation  has  taken  place  the  mass  becomes  solid  but  is, 
still  soft  and  yielding  to  the  touch  ;  the  uterus  is  displaced,  usually 
upward  and  forward,  so  that  the  cervix  will  be  found  just  behind 
or  above  the  symphysis.  The  rectal  touch  will  also  show  that  the 
tumor  presses  upon  the  bowel ;  abdominal  palpation  made  after  the 
tympanitic  distention  has  subsided  will  often  show  the  mass  extend- 
ing up  to  the  superior  strait,  and  sometimes  higher,  and  in  one  case 
that  I  saw,  the  blood-clot  extended  upward  halfway  to  the  umbilicus. 

After  inflammation  takes  place  this  mass  becomes  surrounded 
above  with  the  products  of  the  inflammation,  which  increase  the 
density  of  the  tumor  and  also  give  it  a  more  perfect  fixation.  After 
the  inflammation  has  subsided  and  the  serous  portion  of  the  blood 
has  all  been  absorbed  and  the  solid  clot  has  undergone  considerable 
contraction,  the  mass,  that  was  originally  smooth  to  the  touch,  now 
becomes  quite  irregular.  As  the  case  advances  still  further  and  the 
blood-clot  breaks  down  and  suppuration  occurs,  the  mass  may  be- 
come softer  atid  give  the  impression  of  obscure  fluctuation  to  the 
touch.  The  great  difiiculty  which  the  diagnostician  encounters  is  to 
distinguish  between  pelvic  cellulitis,  pelvic  peritonitis,  and  haemato- 
cele.  It  is  also  stated  that  pelvic  hasmatocele  may  be  confounded 
42 


642  DISEASES  OF  WOMEN. 

with  retroversion  of  the  uterus,  extra-uterine  pregnancy,  fibroid 
tumors,  and  inflammation  of  a  small  ovarian  cyst  which  is  lodged  in 
the  sac  of  Douglas,  and  hydro-  or  pyo-salpinx.  There  is  very  little 
likelihood  of  confounding  so  grave  an  affection  as  pelvic  hgemato- 
cele,  the  clinical  history  of  which  is  so  marked,  with  any  of  the 
above-named  conditions,  except  it  might  be  an  acute  inflammation 
of  an  ovarian  cyst,  located  in  the  sac  of  Douglas,  or  a  Fallopian  tube, 
very  greatly  distended  with  serum,  pus,  or  blood.  In  either  of  these 
conditions — except  the  latter — if  a  diagnosis  could  not  be  made,  and 
it  was  important  at  once  to  do  so,  the  use  of  the  hypodermic  syringe 
used  as  an  aspirator  would  settle  the  question  definitely. 

Treatment. — During  the  stage  of  haemorrhage  this  consists  in 
using  means  to  arrest  the  hfemorrhage,  relieve  the  pain,  and  sustain 
the  patient  against  the  shock  and  loss  of  blood.  To  control  the  haem- 
orrhage the  patient  should  be  placed  on  the  back  with  the  head 
and  shoulders  slightly  elevated,  in  order  that  the  blood  as  it  accu- 
mulates in  the  pelvis  may  by  its  own  weight  make  pressure  upon 
the  rupture  in  the  vessel.  Cold  applications  to  the  abdomen  have 
been  recommended,  but  usually  are  not  well  borne.  Pressure  made 
by  applying  a  compress  and  bandage  is  more  likely  to  do  good.  To 
relieve  the  pain  and  sustain  the  patient,  morphine  given  hypoder- 
mically  is  the  most  reliable  and  valuable  of  all  remedies ;  under  the 
circumstances  the  opium  acts  as  a  stimulant  as  well  as  a  relief  to 
pain.  In  case  the  shock  is  great  and  liable  to  prove  fatal,  stimulants 
should  be  used  hypodermically  or  by  the  rectum  ;  but  in  many  cases 
the  rectum  will  not  retain  them  owing  to  the  irritability  caused  by 
the  hsematocele. 

This  line  of  treatment  is  efficient  in  the  subperitoneal  variety, 
and  in  the  intra-peritoneal  also  in  case  the  ruptured  vessel  is  small ; 
but  in  the  latter  it  is  necessary,  in  the  majority  of  cases,  to  open  the 
abdomen  and  stop  the  haemorrhage  by  ligating  the  ruptured  vessels. 

When  the  inflammatory  stage  begins  the  treatment  should  be  the 
same  as  that  already  advised  in  cases  of  pelvic  peritonitis,  and  if  the 
case  progresses  favorably  the  treatment  should  be  continued  on  the 
same  principle.  If,  hoM-ever,  suppuration  takes  place  and  the  patient 
is  placed  in  danger  of  septicaemia,  the  question  arises  how  to  relieve 
that  condition.  There  are  two  methods,  either  or  both  of  which  may 
be  employed  if  the  location  of  the  pus  can  be  reached  through  the 
vagina ;  aspiration  may  be  practiced,  and  if  that  gives  relief  it  may 
be  repeated  if  need  be ;  if,  however,  this  fails,  the  needle  may  be 
again  introduced  until  the  pus  is  reached,  and  being  left  there  as  a 
guide,  a  larger  opening  may  be  made  and  drainage  established. 


PELVIC   IIvEMATOCELE.  643 


ILLUSTRATIVE   CASES. 

A  Case  of  Pelvic  Haematocele  uncomplicated. — A  lady  of  some- 
what phlegmatic  temperament  who  was  also  chlorotie,  had  suffered 
all  her  life  from  djsmenorrhoea  in  a  marked  degree,  and  also  scanty 
menstruation  as  a  rule,  although  at  times  this  was  more  free.  She 
had  been  twice  married,  the  last  time  for  eight  years,  but  had  never 
been  pregnant.  In  taking  her  previous  history  at  the  time  I  lirst 
saw  her,  I  found  that  she  had  symptoms  of  some  former  pelvic  dis- 
ease, probably  general  congestion  as  indicated  by  her  dysmenorrhoea, 
leucorrhoea,  and  pelvic  tenesmus  which  was  aggravated  on  walking. 

She  had  lived  a  somewhat  indolent  life  taking  very  little  phys- 
ical exercise.  "When  I  saw  her  iirst  I  learned  that  on  the  last  day  of 
her  menstrual  flow  she  had  been  riding  and  walking  more  than 
usual,  as  she  had  some  visitors  whom  she  was  entertaining  by  tak- 
ing them  about  the  city. 

While  getting  out  of  her  carriage  she  slipped  and  fell  on  the 
sidewalk ;  she  was  taken  with  pain  in  the  left  side  of  her  pelvis,  and 
had  to  be  helped  into  the  house,  and  immediately  went  to  bed ;  her 
pain  increased  in  severity,  and  she  became  very  faint  and  nauseated  ; 
I  saw  her  about  two  hours  after  this  slight  accident,  and  found  her 
suffering  from  partial  shock ;  her  pulse  was  exceedingly  feeble  and 
rather  rapid ;  her  temperatm:'e  was  97^°  F.,  and  her  skin  was  cold 
and  clammy ;  she  was  sighing  frequently,  and  had  an  expression  of 
extreme  anxiety  and  distress  ;  she  had  vomited  frequently  and  was 
exceedingly  nauseated ;  she  complained  in  a  low  whispering  voice  of 
a  violent  pain  in  the  vaginal  pelvis.  There  was  considerable  tympa- 
nitic distention  of  the  abdomen  with  marked  tenderness  in  the  epi- 
gastric region.  On  digital  examination  I  found  considerable  tender- 
ness, but  not  as  much  as  might  have  been  expected. 

There  were  signs  of  fluid  in  the  sac  of  Douglas,  but  this  was  eas- 
ily displaced  by  the  touch ;  a  diagnosis  of  pelvic  hsemorrhage  was 
made,  and  hypodermic  injections  of  morphine  were  given  sufficient 
to  relieve  her  pain  ;  a  little  brandy-and-w^ater  was  also  administered 
at  first,  but  this  she  almost  immediately  rejected  ;  an  abdominal  band- 
age and  compress  were  applied  without  giving  any  distress  for  two 
or  three  hours,  but  at  that  time  she  complained  of  its  tightness,  and 
it  was  necessary  to  remove  it ;  bottles  of  hot  water  were  applied  to 
the  feet  and  limbs  and  also  to  the  arms,  which  were  kept  under  the 
bed-clothing.  All  this  gave  her  relief  from  pain  to  some  extent 
and  the  shock  did  not  apparently  increase,  and  yet  she  showed  very 
little  disposition  to  rally.     About  three  hours  afterward  some  brandy 


644  DISEASES   OF  WOMEN. 

and  beef-extract  were  given  bj  enema,  and  repeated  at  intervals  of 
two  or  three  hours  for  some  time  ;  the  hypodermic  injections  of 
morphine  were 'also  repeated  as  often  as  every  three  hours  during 
the  first  twelve  hours.  During  this  time  she  was  given  a  grain  and 
a  half  of  morj)hia  altogether.  She  then  began  slowly  to  recover 
from  her  shock,  the  haemorrhage  evidently  having  stopped  ;  her 
pulse  became  more  rapid  and  a  little  fuller ;  she  breathed  more  nat- 
m-ally,  and  her  skin  became  warm ;  she  also  had  less  of  that  extreme 
faintness  and  depression  ;  still  she  remained  nauseated  although  she 
was  able  to  retain  very  small  quantities  of  brandy  and  Seltzer-water 
and  beef-extract ;  the  pain  however  was  not  any  less  except  when 
controlled  by  the  morphine.  In  addition  to  this  she  complained  of 
marked  pelvic  tenesmus,  especially  of  the  bladder  and  rectum.  She 
described  this  feeling  as  one  of  great  fullness,  weight,  and  pressure 
in  the  pelvis,  which  she  fancied  would  be  relieved  by  free  evacua- 
tion of  the  bowels.  She  remained  in  this  condition  with  very  little 
change ;  taking  opium  freely  and  very  little  nourishment  for  about 
forty-eight  hours ;  at  that  time  the  physical  signs  showed  that  the 
sac  of  Douglas  was  filled  with  blood  which  was  now  beginning  to 
coagulate  as  shown  by  the  less  pelvic  fluctuation  on  touch.  Her 
temperature  now  rather  rapidly  increased,  running  up  to  103°  F., 
her  pulse  became  more  rapid  and  fuller ;  the  pain  also  increased, 
and  nausea  and  vomiting  again  returned.  She  was  now  very  tym- 
panitic and  had  acute  tenderness  on  touch  in  the  lower  part  of  the 
abdomen ;  in  short,  she  had  all  the  symptoms  of  acute  pelvic  peri- 
tonitis with  unusual  marked  constitutional  disturbance,  owing  no 
doubt  to  the  general  depressed  condition  due  to  pelvic  haemorrhage. 

On  the  fourth  day  there  were  well-defined  evidences  that  the 
products  of  the  pelvic  inflammation  were  being  developed  ;  there 
was  much  greater  hardening  of  the  parts,  and  the  mass  in  the  sac  of 
Douglas  was  solid  or  more  solid  as  indicated  by  the  touch.  From 
this  onward  the  physical  signs  were  those  of  a  pelvic  peritonitis 
with  an  unusual  accumulation  in  the  sac  of  Douglas. 

The  progress  of  the  case  from  this  time  was  that  of  a  severe  pel- 
vic peritonitis,  and  the  treatment  was  the  same  as  has  already  been 
described,  hence  nothing  further  need  be  said  on  that  subject.  At 
about  the  end  of  the  third  week  the  physical  signs  were  the  same, 
except  that  on  examination  a  mass  appeared  behind  the  uteras  which 
was  somewhat  irregular,  small  depressions  and  elevations  being  de- 
tected here  and  there  ;  the  temperature  and  pulse  had  both  come 
down,  and  yet  remained  above  100  ;  the  patient  was  now  able  to  take 
a  fair  amount  of  nourishment,  and  her  bowels  were  moved,  but  with 


PELVIC   HEMATOCELE.  645 

the  greatest  possible  difficulty  ;  laxatives  and  repeated  enemata  were 
given  each  time  that  an  evacuation  was  obtained,  and  she  also  suf- 
fered great  distress  when  the  bowels  moved.  About  this  time  she  be- 
gan to  show  decided  malnutrition ;  she  had  lost  considerable  flesh, 
was  pale  and  rather  slightly  bronzed  looking,  and  her  skin  was  dry 
and  ill  conditioned,  giving  the  impression  that  the  absorption  of  the 
serous  portion  of  the  blood  was  probably  causing  a  mild  fonn  of 
septicaemia.  From  this  time  onward  her  progress  was  exceedingly 
slow  but  entirely  satisfactory  under  tonics,  nourishing  diet,  and  mild 
counter-irritation  over  the  hypogastric  region ;  she  gradually  re- 
gained her  strength.  The  pain  and  discomfort  in  the  pelvic  region 
had  become  very  trifling  except  when  she  tried  to  take  exercise. 
There  was  no  change  in  the  physical  signs  except  that  the  mass  in 
the  sac  of  Douglas  had  greatly  diminished  in  size,  and  the  uterus 
which  had  been  pushed  upward  and  forward  close  to  the  pubes,  had 
returned  in  part  toward  its  normal  position.  The  hardening  of  the 
pelvic  roof  and  the  fixation  of  the  pelvic  organs  remained  about  the 
same. 

It  is  needless  to  follow  the  progress  of  this  case  from  day  to  day ; 
suffice  it  to  say  that  she  made  a  very  slow  recovery,  that  at  each 
menstrual  period  she  suffered  great  disturbance,  and  that  for  a  long 
time  was  unable  to  walk  or  ride  without  suffering  pain.  Tonics, 
alteratives,  and  nourisliing  diet  were  given  which  improved  her  gen- 
eral condition. 

Ten  months  after  the  attack  there  were  still  signs  of  an  excessive 
exudation  in  the  pelvis,  and  also  the  remains  of  a  blood-clot  in  the 
sac  of  Douglas ;  still,  from  this  time  onward  she  was  able  to  enjoy 
life  in  her  own  somewhat  indolent  way,  but  could  not  walk  or  ride 
without  suffering  more  than  in  former  years.  A  year  and  a  half 
subsequently  I  had  the  opportunity  of  examining  the  pelvis,  and 
found  that  there  was  still  considerable  fixation  of  the  pelvic  organs, 
and  also  some  hard,  irregular,  small  masses  in  the  sac  of  Douglas, 
but  she  did  not  appear  to  suffer  very  much  from  these,  and  her  gen- 
eral health  was  fairly  good. 

Pelvic  HsBmatocele ;  Evacuation  of  a  Clot ;  Recovery. — A  French- 
woman, occupied  as  pohsher  in  a  watch-case  factory,  where  her  duties 
required  her  to  occupy  a  standing  position  all  day  long,  was  suddenly 
taken  ill  while  at  work ;  violent  pain,  followed  by  faintness,  came 
on  while  she  was  at  work.  She  was  carried  from  the  factory  to  her 
home  near  by,  and  one  of  my  assistants  was  called  to  see  her.  He 
attended  to  her  immediate  wants,  and  saw  her  again  afterward,  when 
he  made  a  digital  examination,  and  found  a  fluctuating  mass  in  the 


64:6  DISEASES   OF  WOMEN. 

sac  of  Douglas,  On  the  second  day  he  gave  me  a  detailed  history 
of  the  case,  and  we  came  to  the  conclusion  that  she  must  have  had 
a  pelvic  lisemorrhage  ;  the  inflammatory  action  soon  set  in  after  she 
rallied  from  the  shock  which  occurred,  and  was  very  severe  at  the 
onset  of  the  disease,  and  she  was  again  in  a  most  dangerous  condi- 
tion. Being  poor,  her  surroundings  were  very  unsatisfactory,  and, 
by  advice  of  the  doctor,  she  was  removed  to  the  hospital ;  she  was 
admitted  about  ten  days  after  the  time  that  she  was  taken  ill.  At 
that  time  the  pelvis  appeared  to  contain  one  solid  mass,  so  that  noth- 
ing could  be  distinguished  except  a  somewhat  shortened  vagina  and 
the  cervix  uteri,  which  was  curled  up  and  firmly  fixed  behind  the 
pubes.  Her  bowels  were  very  much  distended,  and  she  suffered  ex- 
tremely from  pain  and  tenesmus ;  her  general  condition  was  very 
wretched,  indeed,  and,  as  it  was  impossible  to  move  the  bowels,  the 
question  arose.  What  could  be  done  to  relieve  the  extreme  pressure 
in  the  pelvis  which  threatened  to  destroy  the  organs  and  tissues,  and 
prove  fatal  ?  I  had  the  extreme  good  fortune  to  secure  the  counsel 
of  the  late  Prof.  William  Warren  Greene,  and  we  decided  to  evacu- 
ate the  blood-clot  in  the  hope  of  thereby  saving  the  life  of  the  pa- 
tient ;  accordingly,  an  incision  was  made  through  the  posterior  vag- 
inal wall  into  the  most  dependent  part  of  the  tumor,  which  extended 
well  down  into  the  middle  line  of  the  pelvis ;  a  large  blood-clot 
was  found,  which  was  broken  up  and  evacuated,  and  the  cavity  cau- 
tiously washed  out.  No  haemorrhage  of  any  amount  followed,  and 
she  was  very  much  relieved.  I  succeeded  then  in  moving  the  bowels, 
which,  while  it  distressed  her  at  the  time,  subsequently  gave  her 
relief.  The  improvement  lasted  but  a  little  while,  however,  for  she 
soon  developed  a  violent  septicaemia,  and  it  now  appeared  as  if  she 
certainly  must  die ;  she  became  delirious,  her  pulse  was  extremely 
rapid  and  feeble,  her  temperature  was  105^°  F.,  and  she  was  bathed 
in  clammy  perspiration ;  her  breath  also  had  that  peculiar  sweetish 
odor  characteristic  of  septicaemia  or  pyaemia. 

There  was  a  free  discharge  of  i:)us  at  this  time  from  the  wound. 

Every  effort  was  made  to  sustain  her  by  stimulants  and  quinine, 
given  by  the  mouth  and  rectum  also,  and  the  sac  was  washed  out 
carefully  and  frequently  with  boracic  acid  and  water.  For  two  days 
it  seemed  as  if  she  might  die  at  any  time. 

A  fi"ee  and  profuse  diarrhcea  came  on,  and  lasted  for  several 
hours,  and,  at  a  consultation  held  by  the  surgical  staff  of  the  hosjutal, 
all  agreed  that  she  had  very  little  chance  of  recovery.  The  treat- 
ment was  thoroughly  carried  out,  and  soon  the  l)lood-poisoning  began 
to  diminish,  the  sac  became  smaller,  the  discharge  less  free,  and, 


PELVIC   HEMATOCELE.  64:7 

finally,  the  wound  closed,  and  she  recovered  from  all  but  the  prod- 
ucts of  the  inflammation,  and  these  remained  slightly  diminished  up 
to  the  time  that  she  was  discharged  from  the  hospital,  three  months 
from  the  time  that  she  was  admitted.  When  she  left  the  hospital 
her  general  health  was  fairly  good,  but  there  was  still  fixation  of  the 
pelvic  organs,  and  marked  induration  extending  across  the  pehds 
behind  the  broad  ligament  and  uterus.  1  found  out  afterward  that 
she  took  care  of  her  household  after  her  return  from  the  hospital, 
and  about  six  months  afterward  returned  to  her  occupation  in  the 
factory,  where  she  remained  at  work  when  last  heard  of,  two  years 
from  the  time  she  was  first  taken  sick. 

A  Case  of  Subperitoneal  Hsematocele ;  Recovery. — A  lady,  whose 
age  does  not  appear  in  my  notes,  was  married,  and  had  three  chil- 
dren, and  was  under  my  care  for  endometritis,  associated  with  a  good 
deal  of  general  congestion  of  the  pelvic  organs.  She  was  progressing 
fairly  well  until  one  day,  when  she  went  to  New  York  shopping ; 
she  walked  and  stood  considerably,  and  on  her  way  home  in  the 
afternoon,  after  crossing  the  ferry,  decided  to  walk  to  her  house,  a 
distance  of  about  three  quarters  of  a  mile ;  she  did  this  because  she 
was  somewhat  proud  of  her  improvement  under  treatment.  When 
about  half  through  her  short  journey,  she  was  seized  with  pain  in  the 
left  side  of  the  pelvis,  which  became  so  severe  that  she  was  obliged 
to  sit  down  on  the  door-steps  of  a  house  near  by,  and,  after  resting 
for  a  short  time,  she  managed  to  get  home,  went  to  bed,  and  applied 
a  mustard-paste  over  the  painful  side ;  the  next  day  or  two  she  re- 
mained in  bed,  the  pain  gradually  diminishing,  though  it  did  not 
wholly  disappear.  Four  days  afterward  she  rode  to  my  office,  and, 
on  digital  examination,  I  found  a  round,  rather  flat  tumor  in  the  left 
broad  ligament,  low  down  ;  it  was  somewhat  sohd  to  the  touch,  and 
tender.  Being  very  desirous  of  knowing  what  this  peculiar  and  sud- 
denly developed  tumor  could  be,  I  introduced  a  small  aspirating- 
ueedle,  and  drew  off  a  few  drops  of  blood-serum  and  a  few  very 
minute  shreds  of  blood-clot,  but  failed  to  find  anything  more,  al- 
though I  made  a  strong  effort  to  do  so.  I  then  withdrew  the  needle, 
and  found  that  it  contained  a  long  shred  of  blood-clot ;  this  satisfied 
me  that  she  had  had  a  haemorrhage  into  the  cellular  tissue  of  the 
broad  ligament.  I  watched  her  with  care  and  anxiety,  but  there  was 
no  inflammatory  action  established  at  that  point,  and  the  tumor 
slowly  and  completely  disappeared. 

Subperitoneal  Pelvic  Haematocele  discharging  into  the  Pertioneal 
Cavity,  and  ending  fatally. — The  following  case  is  taken  from  the 
work  of  Thomas  on  "  Diseases  of  Women  "  :  "  In  a  case  which  I  saw 


648  DISEASES   or   WOMEN, 

with  Dr.  Emmet,  we  were  unable  to  make  a  diagnosis  of  a  tumor 
which  lay  obliquely  anterior  to  the  uterus.  In  twenty-four  hours 
the  patient  fell  into  a  state  of  collapse,  and,  as  we  saw  her  thus,  the 
nature  of  the  tumor,  which  we  were  doubtful  about  on  the  previous 
day,  became  evident.  Upon  a  post-mortem  examination,  an  ante- 
uterine  hsematocele  as  large  as  a  goose's  egg  was  found  under  the 
peritonaeum,  through  which  it  had  broken,  discharged  a  portion  of 
its  contents  into  the  peritonaeum,  and  caused  collapse  and  death. 
This  is  the  only  ante-uterine,  but  not  the  only  subperitoneal,  hsema- 
tocele  with  which  I  have  met." 

For  an  illustration  of  subperitoneal  pelvic  hsematocele  giving 
rise  to  cellulitis  and  suppuration,  the  reader  is  referred  to  a  case 
given  under  the  head  of  "  Pelvic  Cellulitis." 


CHAPTEK  XXXY. 

ECTOPIC    GESTATION. 

The  subject  of  ectopic  gestation  is  one  of  such  importance  as  to 
have  induced  me  to  write  a  chapter  upon  it.  Much,  if  not  all,  that 
has  been  done  of  late  years  to  advance  our  knowledge  of  the  matter 
has  come  from  the  gynsecologists,  and  the  management  of  these 
,  cases  has  naturally  fallen  into  the  hands  of  those  who  are  skilled  in 
abdominal  and  pelvic  surgery. 

The  term  ectopic  gestation  is  applied  to  the  implantation  and 
development  of  the  impregnated  ovum  outside  of  the  cavity  of  the 
uterus.  In  the  past,  authors  have  held  that  there  was  a  great  variety 
of  these  peculiar  gestations,  which  were  classified  according  to  the 
location  of  the  ovum.  Tubal,  ovarian,  abdominal,  and  interstitial, 
were  all  said  to  occur  frequently.  Further  investigation  has  led  to 
the  conclusion  that  tubal  gestation  is  either  the  only  primary  form, 
or  at  least  that  any  other  origin  than  in  the  tube  is  rare.  That 
ovarian  pregnancy  may  exist,  is  shown  by  the  cases  of  Bandl  and 
JSTouratoff. 

In  the  interstitial  form  the  ovum  grows  in  that  part  of  the  tube 
occupying  the  wall  of  the  uterus,  and  as  the  ovum  enlarges  the  uter- 
ine wall  splits  and  develops  to  accommodate  it.  I  feel  satisfied  that 
many  so-called  cases  of  ectopic  gestation  are  really  gestation  in  one 
horn  of  an  imperfectly  developed  uterus.  The  abdominal  variety 
was  supposed  to  arise  from  an  impregnated  ovum  which  had  become 
fixed  in  the  peritoneal  cavity  and  developed  there.  Recent  obser- 
vations show  that  such  cases  are  primarily  tubal  gestation,  that  rup- 
ture of  the  tube  occurs,  and  that  the  ovum  escapes  and  forms  an 
attachment  to  the  peritonaeum. 

A  statement  which  would  express  the  modern  views  is  about  as 
follows :  All  cases  are  at  first  tubal.  Rupture  of  the  tube  takes 
place  in  all  cases,  as  a  rule,  and  the  ovum  escapes  either  into  the 
peritoneal  cavity,  or  in  between  the  folds  of  the  broad  ligament. 
After  escape  of  the  ovum  in  one  or  the  other  direction,  the  ovum 
may  live  and  develop  into  either  the  intraperitoneal  or  extraperito- 

649 


650  DISEASES  OP  WOMEN. 

neal  variety.  In  the  extraperitoneal  variety  a  second  rupture  may 
take  place,  and  thus  it  may  become  intraperitoneal,  or  the  ovum 
may  develop  to  maturity  in  the  broad  ligament. 

Pathology. — There  is  at  all  times  some  abnormal  condition  of 
the  sexual  organs  which  renders  extra-uterine  gestation  possible. 
This  will  be  referred  to  when  treating  of  causation. 

The  natural  tendency  in  tubal  gestation  is  for  rupture  to  take 
place  with  escape  of  the  ovum.  Rupture  occurs  before  the  four- 
teenth week  in  ninety  per  cent  of  the  cases.  Previous  to  the  com- 
plete rupture  there  are  occasionally  minor  lacerations  of  the  perito- 
neal covering  of  the  tube.  Especially  is  this  likely  to  take  place 
when  there  has  been  peritonitis  which  has  impaired  the  nutrition 
and  elasticity  of  this  serous  membrane.  There  are  usually  slight 
haemorrhages  either  into  the  tube  or  into  the  peritoneal  cavity, 
attended  with  pain  in  the  earlier  lacerations.  When  rupture  oc- 
curs, death  ensues  in  most  cases,  unless  relief  is  afforded  by  oper- 
ating. Death  is  caused  by  ha3morrhage  and  shock  in  the  majority, 
but  some  survive  this,  and  finally  succumb  to  peritonitis  or  septi- 
caemia from  suppuration. 

In  case  of  rupture  the  ovum  may  plug  the  opening  and  arrest 
the  hsemorrhage ;  the  placenta  may  form  attachment  to  the  perito- 
naeum, and  the  gestation  go  on  to  full  term  as  an  abdominal  preg- 
nancy. This  is,  perhaps,  one  way  in  which  an  abdominal  pregnancy 
may  occur,  but  it  is  rare. 

Finally,  the  ovum  may  die  in  the  tube  and  become  encysted,  or 
disappear  by  absorption. 

Causation. — There  is  really  very  little  known  about  the  etiology 
of  ectopic  gestation.  Several  theories  have  been  advanced  with 
much  positiveness,  but  there  are  few  facts  to  sustain  them.  It  is 
known  that  the  ovule  usually  becomes  impregnated  in  the  Fallopian 
tube,  but  why  it  should  attach  itself  to  the  mucous  membrane  of  the 
tube  and  develop  there  is  not  clearly  made  out.  Johnston  states, 
in  the  Transactions  of  the  American  Gynaecological  Society  for  1890, 
that  the  mucous  membrane  of  the  tube  and  the  peritonaeum,  when 
divested  of  their  epithelium,  are  capable  of  forming  a  nidus  in  which 
an  ovum  may  develop,  and  disease  of  the  tube  causes  such  exfolia- 
tion of  the  epithelium.  The  old  theory  is,  that  some  narrowing  of 
the  tube  which  would  obstruct  the  passage  of  the  ovum  to  the  uterus, 
at  the  same  time  that  all  other  conditions  were  favorable,  would  lead 
to  such  result.  In  later  times  it  is  supposed  that,  owing  to  some 
disease  of  the  endometrium,  the  impregnated  ovum  is  retarded  in 
its  transit  or  entrance  to  the  uterus,  and,  tinding  favorable  condi- 


ECTOPIC   GESTATION.  651 

tions  in  the  tube,  remains  to  develop  there.  Another  explanation 
of  the  retention  of  the  ovum  in  the  tube  is,  that  there  are  often- 
times small  diverticula  in  the  lower  side  of  the  tube  into  which  the 
ovum  may  fall  and  be  retained.  After  all,  it  is  evident  that  but  little 
is  known  definitely  on  this  subject  that  can  be  positively  stated. 

Symptomatology. — It  is  of  the  highest  importance  that  a  diag- 
nosis should  be  made  in  ectopic  gestation  as  early  as  an  opportunity 
is  afforded  to  do  so,  No  matter  what  the  treatment  may  be,  the 
medical  attendant  has  great  advantages  if  he  knows  the  nature  of 
the  case  before  being  called  upon  to  interfere  by  operative  or  other 
means.  On  this  account  the  symptomatology  has  a  special  interest 
which  I  desire  to  direct  attention  to,  especially  so  because  in  the 
past  few  years  much  has  been  said  about  the  difticulty  or  impossi- 
bility of  making  a  diagnosis.  An  experience  neither  more  nor  less 
than  that  which  usually  falls  to  the  lot  of  one  in  twenty  years'  prac- 
tice has  led  me  to  believe  that  the  diagnosis  of  ectopic  gestation  is 
just  as  possible  as  of  normal  gestation.  There  are  exceptional  cases, 
I  know  quite  well ;  but  the  rule  is,  that  one  can  be  as  sure  of  the 
presence  of  an  ectopic  gestation  as  of  any  of  the  various  forms  of 
internal  disease. 

The  Signs  and  Symptoms  of  Tubal  Pregnancy. — These  may  be 
prefaced  by  the  statement  that  a  considerable  period  of  sterility 
usually  precedes  the  history  of  such  a  case.  On  examination  we 
shall  find  many  of  the  following  conditions : 

1.  The  signs  of  pregnancy  are  present.  Menstruation  ceases,  or 
is  replaced  by  the  peculiar  haemorrhages  mentioned  below.  Nausea 
and  vomiting,  salivation,  and  changed  appetite  are  noted.  "We  find 
some  of  the  early  mammary  signs,  such  as  increase  in  size  and  firm- 
ness of  the  gland,  erectility  of  the  nipple,  glandular  follicles,  pig- 
mentation, 03dema  and  elevation  of  the  primary  areola,  and  enlarged 
veins.  Pelvic  discomfort  is  marked.  Compared  with  normal  preg- 
nancy, the  signs  are  often  more  pronounced.  In  most  of  the  cases 
I  have  seen  the  patients  have  been  irritable  and  apprehensive. 

2.  Hgemorrhages  from  the  uterus  occur  usually  in  gushes  of 
larger  or  smaller  amount,  and  they  are  especially  liable  to  appear 
at  the  time  of  the  painful  paroxysms.  The  hemorrhages  and  the 
cast  often  suggest  miscarriage. 

3.  A  decidual  cast  is  thrown  off,  and  this  cast  has  no  fatal  vil- 
losities.  It  may  be  entire,  or  may  be  discharged  piecemeal.  Shreds 
must  be  looked  for. 

4.  The  patient  suffers  from  paroxysms  of  pain  which  are  "  abrupt, 
violent,  supervening  on  apparent  health,  cramp-like  in  character, 


652  DISEASES  OF  WOMEN. 

and  usually  referred  to  the  seat  of  the  fruit-sac,  while  the  more  acute 
paroxysms  are  attended  with  collapse  and  signs  of  internal  haemor- 
rhage." 

On  bimanual  examination  the  uterus  is  found  (1)  to  be  enlarged  ; 

(2)  it  is  displaced  according  to  the  size  and  situation  of  the  fruit-sac  ; 

(3)  the  cervix  is  open ;  and  (4)  the  uterine  cavity  is  empty.  When 
metrorrhagia  exists  or  the  decidua  has  been  expelled,  there  need  be 
no  hesitation  in  using  the  sound.  The  tumor  which  is  detected 
beside  the  uterus  or  behind  it  is  a  cyst,  (1)  tense,  (2)  tender,  (3)  pul- 
sating, and  (4)  rapidly  growing.  This  tumor  is  extremely  sensitive. 
There  is  evidence  of  extraordinary  vascularity  in  the  pulsating  ves- 
sels which  are  easily  felt,  and  this  is  a  sign  seldom  found  except  in 
intraligamentous  fibroma  and  occasionally  in  cancer.  The  rapidity 
of  growth  is  striking  as  it  is  watched  from  week  to  week,  and  fre- 
quent examinations  are  therefore  required.  No  other  cyst  likely  to 
be  confounded  with  it  increases  with  the  same  rapidity.  In  the 
absence  of  adhesions,  ballottement  of  the  whole  tumor  is  said  to  be 
feasible,  but  I  believe  it  to  be  difiicult.  Contractions  of  the  tube,  in 
imitation  of  the  uterus,  have  been  detected  as  the  time  of  rupture 
approached. 

The  tumor  must  be  differentiated  from  hydrosalpinx  or  pyosal- 
pinx,  small  ovarian  cyst  and  pregnancy  in  one  horn  of  a  double 
uterus,  but  the  only  conditions  that  I  have  seen  which  are  difficult 
to  distinguish  from  tubal  gestation  are  pregnancy  in  a  iiterus 
bicornis  and  haematocele.  The  presence  of  the  other  horn  of  the 
uterus,  and  the  fact  that  the  pregnant  horn  is  continuous  from  the 
cervix  upward,  and  the  tumor  denser  than  a  distended  tube,  are  suf- 
ficient. This  I  feel  sure  of,  having  made  a  differentiation  in  several 
cases.  A  small  pelvic  hagmatocele,  if  seen  soon  after  the  haemor- 
rhage, can  not  be  distinguished  from  the  tumor  of  ectopic  gestation, 
except  by  the  difference  in  history.  The  presence  of  the  products 
of  peritonitis  which  preceded  the  gestation,  and  also  a  uterine  fibroma, 
as  complications,  may  make  a  positive  diagnosis  impossible. 

Sy7nptoms  developed  when  Rupture  takes  place. — When  the  rup- 
ture opens  into  the  peritoneal  cavity  the  symptoms  are  extremely 
grave.  The  pain  is  agonizing  ;  the  surface  of  the  body  becomes  cold 
and  is  bathed  in  clammy  perspiration  ;  the  pulse  is  feeble  and  rapid  ; 
the  temperature  becomes  subnormal,  and  there  is  nausea,  while  dis- 
tention of  the  bowels  from  flatus  soon  comes  on.  In  short,  there 
is  shock,  and  it  gradually  becomes  more  profound  as  the  haemor- 
rhage continues.  If  relief  is  not  afforded  the  patient  dies  from 
shock.    In  case  the  bleeding  ceases  and  the  patient  rallies,  the  symp- 


ECTOPIC  GESTATION.  653 

toms  of  shock  gradually  give  way  to  evidences  of  peritonitis ;  and 
if  this  does  not  prove  fatal,  septicaemia  may  supervene,  or,  more 
]-arely,  recovery  may  follow. 

When  the  rupture  opens  into  the  broad  ligament,  pain  and  symp- 
toms of  depression  are  present,  but  the  shock  is  not  marked.  The 
symptoms  are  like  those  of  subperitoneal  hsematocele,  and  are  not 
violent  in  all  cases. 

Physical  Sig?is  jpresent  when  Rujptiii'e  has  taken  place. — The 
signs  at  this  stage  are  of  value  in  determining  the  direction  of  the 
rupture.  In  the  intraperitoneal  variety,  the  sac  of  Douglas  becoming 
filled  with  blood,  the  soft,  fluctuating  hgematocele  can  be  felt  through 
the  vagina.  This,  taken  in  connection  with  the  violent  symptoms, 
confirms  the  diagnosis,  and  enables  the  surgeon  to  operate  with  more 
certainty  of  avoiding  the  extraperitoneal  variety.  In  the  subperito- 
neal variety  the  tumor  is  lower  in  the  pelvis  and  is  solid  to  the  touch 
from  the  first,  and  in  this  way  can  be  made  out  with  sufiicient  cer- 
tainty to  enable  one  to  forego  operation  for  the  time  being,  which 
is  the  wise  course  to  pursue. 

Treatment. — The  management  of  ectopic  gestation  involves  many 
questions.  The  course  to  be  pursued  must  depend  upon  the  stage  of 
the  gestation  and  the  character  or  form  of  each  case  in  hand. 

In  cases  which  come  under  observation  before  rupture  has  taken 
place  the  life  of  the  embryo  should  be  arrested.  This  principle  of 
treatment  has  for  a  long  time  been  advised,  and  several  methods  of 
accomplishing  this  object  have  been  advocated.  Electricity,  accord- 
ing to  the  latest  reports,  is  the  safest  and  surest  of  all  forms  of  treat- 
ment, and,  notwithstanding  much  opposition  from  certain  quarters, 
I  feel  bound  to  advocate  it. 

Some  prefer  the  interrupted,  others  the  continuous,  current.  The 
way  of  applying  it  is  to  place  a  cotton-covered  ball  electrode  in  the 
vagina  at  the  place  nearest  to  the  tumor,  and  a  large  flat  sponge  or 
clay  electrode  over  the  abdomen  on  the  side  where  the  tumor  is. 
The  strength  of  the  current  should  be  gradually  raised  until  it  is  as 
strong  as  the  patient  can  bear,  and  continued  from  five  to  eight 
minutes.  This  should  be  repeated  daily  until  the  life  of  the  embryo 
ceases,  which  is  shown  by  the  tumor  becoming  smaller.  To  any 
one  who  has  treated  uterine  fibromata  with  electricity  this  treat- 
ment of  ectopic  gestation  is  easy.  The  manipulations  are  about  the 
same. 

"When  the  gestation  is  arrested  in  this  way  the  ovum  is  disposed 
of  by  absorption.  The  tissues  are  soft,  being  very  largely  composed 
of  water,  and  are  as  readily  taken  up  as  blood-clots.    That  the  ovum 


654  DISEASES  OF   WOMEN. 

may  die  from  natural  causes  and  be  disposed  of  without  detriment  to 
the  patient,  is  admitted,  and  the  same  results  can  and  do  follow  when 
electricity  is  employed  to  secure  the  initial  stage  in  the  process. 

Owing  to  the  opposition  which  has  been  raised  to  this  mode  of 
treatment,  it  seems  necessary  that  a  word  or  two  should  be  said  in 
its  favor,  and  also  to  notice  the  reasons  given  for  the  objections  that 
liave  been  made. 

That  this  method  is  efficient,  I  believe  upon  the  ground  that 
many  operators  have  tried  it  and  found  it  successful.  I  also  have 
seen  cases  so  cured.  The  most  powerful  argument  for  it  is  that  of 
Brothers,  who  collected  fifty-three  cases  treated  by  electricity,  as 
reported  in  the  American  Journal  of  Obstetrics  for  April,  1890. 
By  the  simple,  safe,  and  certain  method  I  recommend,  all  the 
foetuses  were  killed  and  not  one  of  tl>e  mothers  was  lost.  It  is  gross 
unfairness  to  attribute  the  deaths  in  this  table  to  electricity.  The 
fatal  result  in  the  patients  of  Braxton-Hicks,  Duncan,  and  Boulton 
was  due  to  the  other  measures  employed.  In  the  first  case  it  was 
due  to  the  puncture  of  the  cyst  through  the  vagina  five  weeks  later, 
which  started  an  internal  haemorrhage.  With  Janvrin's  patient 
internal  haemorrhage  had  begun,  and  the  case  was  not  a  proper  one 
for  electricity.  Tait  lost  two  out  of  thirty-five  patients  treated  by 
laparotomy,  and  Veit  three  in  twenty.  In  the  hands  of  less  expert 
men  abdominal  section  is  still  more  dangerous.  Electrical  foeticide 
comes  nearest  to  the  spontaneous  method  of  relief.  If  carefully  and 
skillfully  employed,  it  is  safe ;  should  it  fail,  or  if  any  unfavorable 
results  follow,  such  as  suppuration  in  the  tube,  or  rupture,  the  case 
can  still  be  treated  by  abdominal  section. 

The  objections  have  little  weight.  The  first  is,  that  we  have  no 
moral  right  to  sacrifice  the  life  of  a  foetus  under  any  circumstances. 
If  this  objection  came  from  a  certain  class  of  theologians,  it  should 
be  accepted  as  a  guide  in  dealing  with  those  who  desire  to  accept 
tliat  doctrine.  Strange  to  say,  it  comes  from  those  who  urge  and 
advocate  abdominal  section  and  removal  of  the  ovum.  The  argu- 
ment appears  to  be  that  it  is  wrong  to  arrest  ectopic  gestation  with 
electricity,  but  right  to  do  so  by  abdominal  section.  It  has  been 
said  that  the  embryo  may  be  destroyed  by  electricity,  but  the  pla- 
centa will  continue  to  live  and  grow  and  prove  dangerous.  The 
one  or  two  reported  instances  are  very  doubtful.  Brothers's  collec- 
tion contains  no  such  case.  At  the  time  when  electrical  treatinent 
is  indicated  the  placenta  is  only  partiall}^  developed,  and  it  loses  its 
vitality  when  the  death  of  the  fa3tus  occurs.  That  is  the  rule  in 
normal  gestation,  and  there  is  no  proof  that  the  natural  law  is  re- 


ECTOPIC  GESTATION.  655 

versed  in  tubal  gestation.  There  is  said  to  be  danger  of  the  dead 
ovum  causing  suppuration  and  septicaemia.  That  is  true,  but  it 
seldom  does  so ;  and,  as  stated  already,  if  a  case  goes  wrong,  abdomi- 
Tial  section  can  be  employed  with  as  good  results,  or  better  than 
after  rupture  takes  place. 

Finally,  the  most  unfair  argument  of  all  is,  that  those  cases 
claimed  to  be  cured  by  electricity  are  cases  of  mistaken  diagnosis. 
This  is  not  worthy  of  serious  consideration. 

Treatment  after  Primary  Rupture  of  the  Sac. — Abdominal  section 
is  the  method  of  management  which  is  called  for  in  case  rupture 
has  taken  place.  When  symptoms  of  rupture  appear,  the  operation 
should  be  at  once  resorted  to.  If  it  is  possible  to  determine  that 
the  rupture  is  into  the  broad  ligament,  operation  is  not  called  for ; 
but  in  case  there  is  doubt,  the  abdomen  should  be  opened,  and  if 
there  is  no  haemorrhage  into  the  peritoneal  cavity  the  abdomen 
should  be  closed.  "When  the  peritonaeum  is  reached,  the  presence 
of  blood  within  it  is  shown  by  the  dark  color  of  the  translucent 
membrane  and  by  its  bulging,  and,  if  further  evidence  is  required, 
by  nicking  the  peritonaeum  and  passing  in  a  pipette  toward  the  cul- 
de-sac.  The  operation  is  the  same  as  in  removal  of  the  diseased 
tubes.  Search  for  the  tube  should  be  made,  and,  when  found,  it 
should  be  withdrawn  and  its  attachments  ligated  and  the  whole 
removed.  This  controls  the  bleeding,  and  then  the  peritoneal 
cavity  can  be  cleansed  of  blood.  The  wound  is  closed  in  the  usual 
way.  This  operation  is  indicated  and  is  highly  successful  when  the 
ovum  has  died  and  decomposition  has  followed. 

Years  ago  I  saw  a  patient  who  was  not  treated  in  any  way  until 
acute  inflammatory  symptoms  had  developed.  She  was  then  treated 
for  peritonitis,  and  died  of  septicseraia.  Post  mortem,  the  gestation 
sac  was  easily  separated  from  the  peritoneal  adhesion  and  removed. 
This  experience  enabled  me  to  save  the  life  of  a  similar  patient  by 
abdominal  section. 

I  am  more  and  more  disposed  to  operate  as  soon  as  a  presump- 
tive diagnosis  is  made,  unless  the  patient  objects  on  ethical  grounds. 

When  rupture  takes  place  into  the  peritoneal  cavity — that  is,  in 
intraperitoneal  cases — operation  should  be  resorted  to  immediately 
if  the  symptoms  are  urgent. 

When  the  rupture  extends  downward  the  question  of  treatment 
is  changed  in  all  its  important  features.  Those  whose  opinions  are 
most  rational  advise  delay  in  subperitoneal  cases  until  the  ovum 
either  dies  or  continues  to  grow.  Operation  is  indicated  if  after 
the  death  of  the  embryo  there  are  inflammation  and  suppuration 


^56  DISEASES   OF   WOMEN. 

with  evidence  of  coming  septicaemia.  The  treatment,  then,  is  to 
evacuate  and  drain  the  sac  through  the  vagina,  making  the  incision 
with  the  cautery,  according  to  the  method  practiced  by  Dr.  T.  G. 
Thomas  long  ago. 

There  are  some  who  advocate  operating  through  the  vagina 
while  the  ovum  is  still  living  and  growing,  but  I  am  sure  that  this 
is  very  dangerous.  There  is  always  a  strong  possibility  that  the  pla- 
centa may  be  at  the  most  dependent  part  of  the  sac  and  in  the  line 
of  incision,  and  hence  haemorrhage  is  caused  that  can  not  be  con- 
trolled even  when  the  cautery  is  used  in  making  the  incision. 

In  the  subperitoneal  cases  that  have  progressed  to  or  near  the 
fourth  month  I  prefer  the  treatment  devised  and  carried  out  suc- 
cessfully by  Dr.  D.  Berry  Hart,  He  opens  the  abdominal  wall  on 
the  side  down  to  the  peritonaeum,  and,  raising  up  the  peritonaeum, 
opens  the  broad  ligament  and  removes  the  contents  of  the  sac  ex- 
cepting the  placenta,  which  he  leaves  ;  he  then  packs  the  cavity  and 
drains  until  the  placenta  dies  and  can  be  removed  or  washed  out ; 
afterward  the  sac  is  permitted  to  close. 

Dr.  Hart  has  had  iive  successful  cases  of  this  kind,  and  that  gives 
great  confidence  in  the  treatment  of  this  subj^eritoneal  variety  of 
ectopic  gestation.  The  operation  can  be  done  when  the  embryo  is 
still  living,  and  with  far  greater  safety  than  by  either  abdominal 
section  in  the  median  line  or  vaginal  section. 

Operation  after  Rupture  of  the  Sac. — When  secondary  rupture 
occurs,  with  dangerous  haemorrhage,  laparotomy  is  indicated,  just 
as  it  is  in  primary  rupture. 

In  this  condition  the  time  to  operate  and  the  method  of  proce- 
dure are  determined  for  the  surgeon,  to  a  great  extent  at  least.  The 
secondary  rupture  is  indicated  by  the  local  and  constitutional  symp- 
toms, which  in  some  cases  are  comparatively  mild,  while  in  others 
they  are  marked  and  call  for  interference. 

On  opening  the  abdomen,  the  foetus,  which  has  escaped  into  the 
abdominal  cavity,  is  removed,  and  the  cavity  cleared  of  blood.  The 
rent  in  the  sac  is  sought  for  and  all  haemorrhage  arrested.  If  the 
rent  is  in  front,  the  walls  of  the  sac  are  fastened  to  the  parietal 
wound  with  sutures  and  the  sac  drained.  "Wlien  it  happens  that  the 
rupture  is  so  situated  that  it  can  not  be  brought  to  the  wound  in  the 
abdominal  wall,  it  should  be  closed,  and  another  opening,  large 
enough  to  admit  a  drainage-tube  and  the  cord,  made  in  front.  The 
further  treatment  should  be  as  if  the  original  rupture  had  occurred 
in  front.  Drainage  of  the  abdominal  cavity  should  also  be  em- 
ployed. 


ECTOPIC  GESTATION.  657 

Operation  when  the  Foetus  is  Dead. — In  this  condition  it  should 
be  understood  that  while  the  foetus  has  died  the  sac  is  not  rup- 
tured, and  that  the  decomposition  of  the  foetus  causes  danger  from 
septic  infection,  and  the  danger  therefrom  demands  operative  inter- 
ference. 

The  complications  which  may  occur  in  this  state  are  very  vari- 
able. The  length  of  time  that  is  permitted  to  elapse,  and  the  extent 
of  inflammatory  products  or  changes  that  may  take  place,  give  char- 
acteristics that  render  no  two  cases  alike.  Some  cases  are  as  simple 
to  operate  on  as  an  ordinary  abdominal  abscess ;  in  others,  intestinal 
and  other  adhesions  are  found  that  make  the  operation  the  most 
difficult.  The  method  of  procedure  must  depend  upon  the  nature 
of  the  case,  and  the  judgment  and  dexterity  of  the  surgeon  must  be 
the  only  guides. 

The  whole  gestation  sac  may  be  removed  as  easily  and  in  the 
same  way  that  an  ovarian  cyst  is  removed,  the  conditions  being 
favorable.  When  the  adhesions  are  such  that  it  can  not  be  safely 
removed,  as  determined  by  a  careful  exploration,  then  the  sac  should 
be  aspirated  and  its  walls  fixed  to  the  abdominal  wall  and  drained. 
Drainage  of  the  abdominal  cavity  as  well  as  of  the  sac  may  be  neces- 
sary.    As  a  rule,  the  placenta  should  be  removed. 

Operation  at  or  before  Full  Term  when  the  Child  is  Alive. — It  is 
no  easy  matter  to  decide  whether  to  operate  at  once  and  save  the 
child — primary  laparotomy — or  to  wait  until  spurious  labor  has  come 
on,  the  child  has  died,  and  sepsis  threatens — secondary  laparotomy. 
If  we  wait  until  the  child  has  been  dead  two  or  three  months,  the 
placental  vessels  atrophy,  and  the  danger  of  haemorrhage  from  the 
placental  site  after  the  operation  is -vastly  diminished.  Harris  gives 
thirty  per  cent  as  the  death-rate  in  secondary  laparotomy.  Hereto- 
fore the  maternal  mortality  has  been  so  great  after  primary  lapa- 
rotomy (ninety-six  per  cent  previous  to  1880)  that  it  was  not  justi- 
fiable, but  since  the  death-rate  dropped  to  sixty  per  cent  between 
1880  and  1888  (Harris),  and  as  it  has  dwindled  to  twenty-eight  per 
cent  since  1888  (Pozzi),  the  operation  demands  consideration.  The 
sac  is  stitched  to  the  abdominal  wound  and  then  incised.  The  child 
is  removed  and  the  cord  tied.  Then  the  placental  site  may  be  con- 
trolled by  a  haemostatic  suture,  and  the  placenta,  together  with  a  large 
part  of  the  sac,  may  be  removed.  If  this  procedure  is  not  feasible, 
the  placenta  may  be  left  to  come  away  later,  and  the  cavity  carefully 
drained. 

The  after-treatment  consists  in  pumping  out  the  fluid  that  ac- 
cumulates in  the  sac  and  does  not  escape  through  the  tube.  If  the 
43 


658  DISEASES  OF  WOMEN. 

drainage  is  not  perfect  in  this  wise,  the  cavity  should  be  washed  out 
through  the  tube.  This  is  generally  necessary  in  order  to  remove 
the  debris  of  the  placenta  as  disintegration  goes  on.  Portions  of 
the  placenta  are  liable  to  slough,  and  it  is  then  necessary  to  enlarge 
the  wound  to  permit  such  masses  to  escape. 

There  are  certain  complications  which  may  occur.  Several  of 
the  most  common  I  here  refer  to  and  discuss  their  management.  If 
there  is  much  fluid  in  the  sac,  it  should  be  removed  by  tapping.  In- 
testinal adhesions  in  front  should  be  separated  in  the  usual  way,  if 
that  is  possible.  If  not,  the  portion  of  the  sac  which  is  adherent 
should  be  divided  around  the  point  of  contact,  and  allowed  to  remain 
attached  to  the  intestine,  using  the  opening  thus  made  to  extract  the 
child. 

AYhen  the  attachment  of  the  placenta  is  in  front  and  in  the  line 
of  incision,  its  presence  there  is  indicated  by  the  extraordinary  vas- 
cularity and  dark  color  of  the  sac-wall.  This  may  possibly  enable 
the  surgeon  to  avoid  making  the  opening  at  that  point  of  the  sac. 
If  the  placenta  can  not  be  avoided,  the  incision  should  be  quickly 
made  and  the  bleeding  arrested  with  forceps,  until  sutures  can  be 
introduced  through  placenta  and  sac-wall  to  control  the  bleeding. 
Every  effort  should  be  made  to  avoid  the  placenta,  as  it  complicates 
the  operation  greatly. 

In  the  subperitoneal  variety  the  sac  consists  of  the  peritonaeum 
and  broad-ligament  tissue,  and  differs  in  vascularity,  thickness,  and 
character  from  the  intraperitoneal  variety.  The  sac  looks  like  an 
intraligamentous  ovarian  cystoma  or  uterine  myoma.  In  this  con- 
dition of  things  there  is  much  haemorrhage  where  the  sac  is  opened, 
and  the  same  manipulations  are  called  for  that  were  described  in 
speaking  of  opening  the  sac  at  the  point  of  placental  attachment. 

We  may  broadly  summarize  as  follows :  The  intraperitoneal 
form  (of  ectopic  gestation)  should  be  operated  on  when  rupture 
takes  place.  The  subperitoneal  variety  should  be  let  alone  after 
rupture  unless  suppuration  occurs,  and  should  then  be  operated  on 
through  the  vagina. 


DISEASES  OF  THE  UEIISTAEY  OEGAl^S. 


CHAPTER  XXXYI. 

ANATOMY  AND  DEVELOPMENT  OF  THE  BLADDER  AND  UEETHKA. 

This  portion  of  the  present  work  is  undertaken  with  the  full 
assurance  that  the  medical  profession  is  in  need  of  a  systematic  and 
practical  treatise  on  the  diseases  which  affect  the  urinary  organs  of 
the  female  sex,  and  that  such  a  treatise  should  be  included  in  every 
work  on  gynecology  which  lays  claim  to  being  complete.  Those 
engaged  in  active  practice  often  encounter  cases  of  cystic  disease 
among  their  female  patients,  many  of  which  are  exceedingly  trouble- 
some if  not  altogether  impossible  to  manage.  There  is,  moreover, 
but  little  in  English  literature,  at  least,  to  aid  them  when  thus  per- 
plexed with  the  difficulties  of  diagnosis  and  treatment. 

In  considering  this  important  subject  after  the  plan  which  I  have 
adopted,  much  will  be  purposely  omitted,  which,  though  interesting, 
is  not  absolutely  necessary  to  a  clear  understanding  of  its  essential 
principles.  The  conflicting  views  of  various  authors  regarding  un- 
settled questions  will,  when  possible,  be  entirely  disregarded  in  order 
to  make  room  for  the  more  practical  points  which  the  physician  is 
expected  to  carry  with  him  in  his  daily  practice.  In  short,  it  will 
be  my  purpose  to  supply,  so  far  as  I  may  be  able,  the  deficiency  in 
this  branch  of  medical  literature,  the  existence  of  which  a  busy  life 
in  private  practice  and  in  teaching  medical  students  and  post-gradu- 
ates has  demonstrated. 

To  proceed  systematically,  I  will  first  take  up  the  form  and  struct- 
ure of  the  bladder  and  urethra,  and  the  relations  which  they  bear  to 
other  organs  and  tissues  in  the  female,  and  then  pass  on  to  the  con- 
sideration of  their  development. 

Anatomy  of  the  Bladder. — The  bladder  is  a  musculo-membranous 
sac,  situated  in  the  anterior  part  of  the  true  pelvis.  Its  form  varies 
with  the  age  of  the  individual  and  the  degree  to  which  it  is  dis- 

659 


660  DISEASES  OF   WOMEN, 

tended.  In  childhood,  the  vertical  diameter  is  the  longest ;  in  mid- 
dle life,  the  transverse ;  in  old  age,  from  the  sagging  of  the  infe- 
rior fundus  and  gradual  atrophy  of  the  pelvic  organs,  the  vertical . 
again  becomes  the  longest  diameter.  When  empty,  its  walls  are 
closely  coaptated,  and  it  lies  behind  the  pubes.  Between  the  pubes 
and  the  bladder  is  a  space  containing  loose  fat.  When  moderately 
filled,  it  rises  slightly  above  the  pubes,  and  assumes  a  somewhat  ovoid 
shape,  which  is  much  more  marked  during  distention.  In  the  fe- 
male the  bladder  has  a  shorter  antero-posterior  and  a  greater  lateral 
diameter  than  in  the  male. 

The  bladder  in  the  female  is,  for  accuracy  and  convenience  of 
description,  divided  into  corpus  (body),  fun- 
dus (base),  and  cervix  (neck)  (see  Fig.  238). 

The  corpus  is  all  that  portion  of  the  organ 
lying  above  an  imaginary  plane,  passing 
through  the  vesical  openings  of  the  ureters 
and  the  center  of  the  symphysis  pubis.  That 
part  lying  below  this  plane  is  the  fundus  or 
base,  and  is  variously  divided.  The  portion 
which  lies  between  the  vesical  openings  of 
the  ureters  behind,  and  the  vesical  oritice  of 
the  urethra  in  front  (Fig.  239),  is  known  as 
the  trigone,  or  vesical  triangle.  That  portion 
Fig.  238.— Diacram  of  the  of  the  base  lyiug  just  behind  the  ureteric 
an'd  Jundus'^'*''  ''''''"'  openings  is  known  as  the  bas  fond.  This  is 
usually  but  a  slight  depression  in  early  and 
middle  life,  but  in  disease  and  advanced  age  it  often  becomes  a 
deep  pouch  or  sac.  This  is  more  often  the  case  in  the  male  than 
in  the  female.  The  cervix  or  neck  of  the  bladder  is  that  funnel- 
shaped  space  at  the  apex  of  the  trigone,  where  the  bladder  and  ure- 
thra merge  into  each  other. 

The  bladder  has  three  coats — two  complete  and  one  partial  or 
incomplete.  From  without  inward  these  are  the  serous  (incomplete), 
the  muscular,  and  the  mucous.  The  serous  investment  of  the  blad- 
der, like  that  of  all  the  abdominal  and  pelvic  organs,  consists  of 
peritonsBum,  of  which  I  will  sjieak  more  fully  when  I  come  to  con- 
sider the  ligaments  and  topographical  relations  of  this  organ. 

The  middle  or  muscular  coat  has  a  peculiarly  efficient  fiber  ar- 
rangement. Its  layers  have  been  divided  into  two — external  and 
internal — but  so  frequent  and  so  intimate  are  their  interlacements 
that,  though  when  minutely  considered  they  are  two,  practically  they 
act  and  appear  as  one.     The  main  direction  of  the  outer  fibers  is 


ANATOMY  OF  THE  BLADDER.  661 

longitudinal ;  of  the  inner,  circular.  There  is  also  a  thin  stratum 
of  muscular  fiber  lying  just  under  the  mucous  membrane,  and  con- 
tinuous with  the  longitudinal  fibers  of  the  urethra.  The  main  fibers 
are  of  the  unstriped  or  involuntary  kind,  and  take  their  origin  chiefly 
from  the  neck  of  the  bladder. 

According  to  some  authors,  the  sphincter  vesicae  is  formed  by  a 
strong  band  of  muscular  fibers,  varying  from  one  eighth  to  half  an 
inch  in  thickness.  By  others,  and  these  are  perhaps  the  best  au- 
thorities, it  is  claimed  that  there  is  no  true  anatomical  sphincter  of 
the  bladder.  Tlie  function  of  the  sphincter  vesicae  is  said  to  be  per- 
formed by  the  closing  together  of  the  longitudinal  folds  of  the  tis- 
sues at  the  junction  of  the  bladder  and  urethra,  or  by  the  transverse 
semicircular  folds  that  close  over  each  other. 

At  the  base  of  the  bladder  two  little  muscular  slips  arise  from 
the  portion  usually  designated  as  the  sphincter  vesicae,  and  find  in- 
sertion about  the  vesical  openings  of  the  ureters.  These  muscular 
fasciculi  are  but  imperfectly  developed  in  the  female,  and  probably 
have  little  if  any  specific  action. 

The  lining  or  mucous  coat  of  the  bladder  is  like  that  of  the  ure- 
ters and  urethra.  It  consists  of  a  basement  membrane,  supporting 
two  or  more  layers  of  epithelium,  in  some  parts  squamous,  in  others 
cylindrical,  the  whole  lying  upon  an  elastic,  cellulo-vascular  bed  that 
is  fitted  into  the  meshes  of  the  reticulated  muscular  coat  beneath. 

This  mucous  membrane  is  nowhere  attached  closely  to  the  sub- 
jacent muscular  layer,  save  at  the  trigone,  the  neck,  and  about  the 
orifices  of  the  ureters.  Owing  to  the  general  looseness  of  attach- 
ment when  the  bladder  is  partially  or  wholly  contracted,  the  mucous 
membrane  is  thrown  into  rough,  uneven  folds  everywhere,  save  at 
the  points  of  close  attachment  already  mentioned. 

In  the  trigonal  sj^ace  the  membrane  is  thinnei-,  more  closely  ad- 
herent, and  the  surface  epithelium  is  usually  of  the  medium-sized, 
squamous  variety.  The  nerve-supply  to  this  small  space  is  very 
rich,  and,  in  consequence,  it  is  the  most  sensitive  part  of  the  blad- 
der. 

Although  Savage  denies  the  presence  of  glands  or  papillae  in  the 
mucous  membrane  of  the  bladder,  Holden  and  many  others  main- 
tain (and  correctly,  I  think)  that  the  membrane  is  studded  with 
numerous  little  glands  and  follicles,  whose  function  is  to  supply 
mucus  to  the  internal  surface  of  the  organ.  They  are  most  numer- 
ous at  and  about  the  vesical  neck. 

The  trigone  in  the  female  is  a  smaller  space,  and  has  less  dis- 
tinctly marked  boundaries  than  in  the  male.     That  little  elevation 


662 


DISEASES   OF   WOMEN. 


of  mucous  membrane  lying  at  the  very  apex  of  the  trigonal  space, 
and  known  as  the  uvula,  is  also  but  little  developed  in  the  fe- 
male. 

Running  between  the  vesical  orifices  of  the  ureters,  Jurie  claims 
to  have  found  what  he  calls  the  inter-ureteric  ligament,  in  the  ends 
of  which  he  asserts  that  the  ureteric  orifices  are  imbedded.  To  its 
action  he  attributes  the  jsower  that  the  bladder  has  of  preventing 
regurgitation  into  the  ureters.  I  will  speak  more  fully  on  this  point 
presently. 

Normally,  the  bladder  has  three  openings,  one  for  each  ureter, 
and  the  urethral  orifice.  The  openings  of  the  ureters  lie  on  each 
side  of  the  median  line  at  the  base  of  the  bladder,  about  one  inch 
and  a  half  behind  the  vesical  opening  of  the  urethra,  and  about  two 
inches  apart.  The  ureters  pierce  the  bladder-Avall  obliquely,  and  their 
openings  are  so  minute  as  to  be  hardly  visible  to  the  naked  eye. 
Their  points  of  entrance  are  marked  by  a  slight  puckering  in  the 

mucous     membrane. 
^f  /  y  The  third  opening  is 

the  ostium  urethrae 
internum,  which  is  a 
diagonal  slit  at  tlie 
juncture  of  the  vesi- 
cal neck  and  urethra. 
According  to  Ru- 
tenberg,  the  color  of 
the  vesical  mucous 
membi'ane  in  the  liv- 
ing subject  before 
dilatation  is  a  dull, 
grayish  red  ;  but,  as 
dilatation  proceeds, 
and  the  irregular 
folds  are  straightened 
out,  it  becomes  grad- 
ually a  brighter  red, 
and,  when  complete 
distention  is  accom- 
plished, the  minute 
arteries  can  be   seen 


Fig.  '/<39. — Base  and  neck  of  the  bladder  (Savage),  a,  sym- 
physis putjis.  1,  1,  Ureters.  1',  Ureteric  openings. 
2,  3,  Uterine  artery  and  veins.  4,  Outline  of  cervix 
uteri.  5,  Vesical  neck.  6,  Arciis  tendinous  and  vesico- 
pubic muscles.     7,  7,  Pubo-coccygeus  muscles. 


forming  a  beautiful  interlacing  network  on  tlie  bands  of  the  muscu- 
lar reticute.  AVhenever  it  has  been  my  good  fortune  to  see  this 
membrane  in  the  living  subject,  it  has  appeared  to  me  as  being  of  a 


ANATOMY   OF  THE  BLADDER.  663 

gra^ash-pink  color,  not  unlike  that  of  the  mucous  membrane  of  the 
cervix  uteri  when  anaemic. 

The  vascular  supply  of  the  bladder  is  very  free,  being  derived 
from  the  superior,  middle,  and  inferior  vesical  arteries,  and  branches 
from  the  uterine  artery.  They  all  arise  from  the  anterior  trunks  of 
the  internal  iliac  arteries.  The  anastomoses  of  the  arterial  twigs  are 
numerous  and  free.  The  veins  are  also  numerous  and  large,  form- 
ing by  interlacement  and  connection  thick,  tortuous  plexuses  about 
the  base,  sides,  and  neck  of  the  bladder,  and  finally  terminate  in  the 
internal  iliac  veins.  This  plexus  about  the  neck  of  the  bladder  com- 
municates freely  with  that  of  the  labia  minora,  uterus,  and  rectum. 
These  venous  plexuses  are  the  chief  elements  in  the  so-called  "  haem- 
orrhoids of  the  bladder." 

In  their  tortuous  course  these  veins  are  accompanied  by  lym- 
phatics that  seem  to  have  their  origin  in  the  submucous  cellular 
tissue  of  the  bladder.  They  enter  the  glands  situated  about 
the  internal  iliac  artery,  and  from  there  go  to  the  lumbar 
glands. 

The  nerves  of  the  bladder  are  of  two  kinds — spinal  and  sympa- 
thetic. The  spinal  nerves  are  branches,  usually  from  the  fomth, 
sometimes  from  the  third,  and  rarely  from  the  second  sacral  nerve. 
They  terminate  chiefly  in  and  about  the  neck  and  base  of  the  blad- 
der. The  sympathetic  nerves  have  their  origin  from  the  hypogastric 
plexus,  which  lies  in  front  of  and  on  the  last  lumbar  and  first  sacral 
vertebrae.  It  is  formed  by  a  mazy  interlacement  of  numerous  gan- 
glionic fibers,  and  branches  from  the  spinal  nerves,  especially  the 
second  sacral.  Ganglia  are  common,  more  particularly  at  the  point 
of  junction  of  the  spinal  and  sympathetic  nerves.  This  plexus  sends 
branches  to  all  parts  of  the  bladder,  and  to  the  vagina,  uterus,  and 
rectum.  This  common  nerve-supply  to  the  various  j)elvic  organs 
must  be  borne  distinctly  in  mind  in  order  that  the  functional  de- 
rangements and  neuroses  of  the  bladder,  hereafter  to  be  described, 
may  be  thoroughly  understood. 

Anatomy  of  the  Urethra. — The  female  urethra  is  a  musculo-mem- 
branous  canal,  from  one  to  two  inches  in  length,  the  average  being 
about  one  inch  and  three  eighths.  Its  diameter  is  greater  than  that 
of  the  male,  being  about  one  fourth  of  an  inch. 

It  lies  in  the  median  line,  just  under  the  pubic  arch,  and  is  held 
in  position  by  the  median  pubo-vesical  Hgament.  In  the  erect  posi- 
tion it  has  a  direction  upward  and  backward,  and  at  all  times,  when 
normal,  its  axis  closely  coi-responds  to  that  of  the  pelvic  outlet.  It 
terminates  anteriorly  at  the  base  of  the  vestibule  by  an  opening 


664: 


DISEASES  OF  WOMEN. 


i' 


J 


■Ji^^i.^1 


known  as  the  meatus  urinarius,  and  posteriorly  at  the  neck  of  the 
bladder. 

It  has  a  cellular,  a  double  muscular,  and  a  mucous  coat.  Accord- 
ing to  Robin  and  Cadiat,  its  mucous  membrane  is  richer  in  elastic 
tissue  than  any  other  in  the  body.  The  epithelial  covering  of  the 
anterior  or  lowest  portion  is  of  the  pavement  variety,  and  closely 
resembles  that  of  the  vagina,  except  that  it  is  not  so  large.  Figs. 
242  and  243  show  the  difference  between  the 
If  -^'  -V  two.  Posteriorly  and  superiorly  it  is  like  that 
of  the  bladder  —  columnar  and  squamous. 
Scattered  throughout  are  little  papilke,  con- 
taining blood-vessels,  and  near  the  meatus 
there  are  numerous  lacunae  surrounded  by 
villous  tufts.  There  are  also  a  number  of 
small  mucous  glands,  that  in  old  people  often 
contain  black  particles,  like  the  prostatic  con- 
cretions of  the  male. 

Upon  each  side,  near  the  floor  of  the  fe- 
male urethra,  there  are  two  tubules  large 
enough  to  admit  a  No.  1  probe  of  the  French 
scale.  They  extend  from  the  meatus  urinari- 
FiG.  240.  —  Urethra  laid  US  Upward,  from  three  eighths  to  three  quar- 
ters of  an  inch.  Fig.  240  is  a  drawing  from 
a  section  of  the  urethra,  laid  open  by  division 
of  its  posterior  or  vaginal  wall.  The  tubules, 
having  been  distended  by  probes  passed  into  them,  are  plainly  seen. 
Fig.  241  shows  the  same  thing  from  the  opposite  side,  the  ure- 
thra having  been  laid  open  by  section  of  its  an- 
terior wall.  The  space  between  the  tubules  is 
the  floor  of  the  urethra.  From  these  it  will  be 
observed  that  the  tubules  run  parallel  with  the 
long  axis  of  the  ♦urethra. 

They  are  located  l)eneath  the  mucous  mem- 
brane in  the  muscular  walls  of  the  urethra. 
This  is  represented  by  Fig.  242,  which  is  a  draw- 
ing taken  from  a  transverse  section  of  the  ure- 
thra, about  a  quarter  of  an  inch  from  the  meatus. 
The  mouths  of  these  tubules  are  found  upon 
the  free  surface  of  the  mucous  membrane  of  the 
urethra,  within  the  labia  of  the  meatus  urinarius. 
The  location  of  the  openings  is  subject  to  slight 
variation,  according  to  the  condition  and  form 


240.  —  Urethra  laid 
open  with  probes  dis- 
tending the  glands  (pos- 
terior wall  divided). 


Fig.  241.— Urethra  laid 
open  with  probes  in 
Skene's  glands  (an- 
terior wall  divided). 


ANATOMY   OF   THE   URETHRA. 


665 


of  the  meatus.  In  some  subjects,  especially  the  young  and  very 
aged,  and  in  those  in  whom  the  meatus  is  small,  and  does  not  pro- 
ject above  the  plane  of  the  ves- 
tibule, the  orifices  are  found 
about  an  eighth  of  an  inch  with- 
in the  outer  border  of  the  mea- 
tus. When  the  mucous  mem- 
brane of  the  urethra  is  thickened 
and  relaxed,  so  as  to  become 
slightly  prolapsed,  or  when  the 
meatus  is  everted,  conditions  not 
imcommon  in  those  who  have 
borne  children,  the  openings  are 
exposed  to  view  upon  each  side 
of  the  entrance  to  the  urethra. 
What  is  here  described  is  rep- 
resented in  Fig.  244.  The  labia 
of  the  meatus  have  been  slight- 
ly everted  to  bring  the  orifices 
into  view. 

The  upper  ends  of  the  tu- 
bules terminate  in  a  number  of 
divisions,  which  branch  off  into 
the  muscular  walls  of  the  ure- 
thra. By  injecting  one  of  the 
tubules  with  mercury,  and  then  dividing  it,  the  openings  of  the 
branches  can  be  easily  seen. 

This  description  of  the  anatomy  of  these  glands  is  taken  from 
dissections  and  microscopical  examinations  made  by  Drs.  B.  F.  West- 
brook  and  J.  M.  Van  Cott,  Jr.  I  have  called  them  glands  because 
they  differ  in  size  and  structure  from  the  simple  follicles  found  in 
abundance  in  the  mucous  membrane. 

When  I  first  discovered  these  glands  I  presumed  that  they  were 
mucous  follicles  that  were  accidentally  of  unusual  size  in  the  subject 
examined,  but,  having  investigated  more  than  one  hundred  of  them 
in  as  many  different  subjects,  and  finding  them  constantly  present, 
and  so  uniform  in  size  and  location,  I  became  satisfied  that  they  were 
worthy  of  a  separate  place  in  descriptive  anatomy.  The  dissections 
made  by  Dr.  Westbrook,  and  the  pathological  lesions  to  which  these 
structures  are  subject,  confirm  this  belief. 

So  far  as  I  know,  the  anatomy  of  these  glands  has  not  been  de- 
scribed, nor  have  the  diseases  to  which  they  are  subject  been  referred 


Fig. 


242. — Transverse  section  of  urethra  with 
gland  on  either  side. 


666 


DISEASES  OF  WOMEN, 


to  by  pathologists.  At  least  this  much  may  be  said,  that  the  stand- 
ard text-books  on  anatomy  and  gynecology  in  English,  Gennan,  and 
French  contain  no  reference  to  them. 

It  is  easy  to  understand  why  these  insignificant  glands  should 


Fig.  243. — Longitudinal  section  of  urethral  glands. 

have  been  overlooked  by  anatomists,  or,  if  noticed  at  all,  classed  with 
other  mucous  follicles.  It  is  only  when  their  pathology  is  under- 
stood that  their  real  importance  becomes  apparent. 

I  know  nothing  about  their  physiology.  They  serve  some  pur- 
pose in  the  economy,  no  doubt,  but  what  is  their  function  is  a  ques- 
tion to  be  answered  in  the  future.  This  will  doubtless  be  attended 
to  at  an  early  date,  as  the  subject  is  worthy  of  investigation.  The 
pathology  of  these  glands,  so  far  as  has  been  investigated  up  to  this 
time,  is  of  great  practical  interest,  and  there  remains,  no  doubt,  much 
still  to  be  studied.  Clinical  observation  has  already  shown  that 
they  are  subject  to  inflammation  of  various  degrees  of  intensity 
and  duration. 

The  meatus  urinarius  in  the  female  differs  from  that  of  the  male 
in  being  a  puckered  and  somewhat  prominent,  rather  than  a  slit-like 


ANATOMY   OF   THE   URETHRA. 


607 


and  depressed  opening.     The  mucous  membrane  of  the  urethra  is 
tlirown  into  longitudinal  folds  throughout,  save  when  opened  and 
unwrinkled  during  micturition  or  by  arti- 
ficial  dilatation.     When   at   rest   it   is   a 
closed  canal. 

Beneath  the  raucous  membrane  there 
is  a  thick  Hbro-elastic  network  into  which 
the  mucous  glands  dip.  These  are  lined 
with  cylindrical  epithelium  and  surrounded 
by  a  network  of  veins.  This  submucous 
areolar  tissue  has  direct  vascular  connec- 
tion with  the  muscular  layer  that  sur- 
rounds it  by  means  of  cavernous  venous  si- 
nuses, partly  in  the  muscle  and  partly  in 
the  elastic  connective  tissue.  Thus  there 
is  an  arrangement  almost  exactly  like  that 

of  the  corpus   cavernosum    penis   in   the  -t  ''■^'  ^ 

male.     The  venous  plexus  of  the  urethra  -..^=^==4= - 

is  situated  chiefly  at  the  sides,  in  what  is   ^i^-  244.— The  meatus  everted, 

^  showing  the  mouths  of  the 

known  as  the  urethrO-publC  space.  glands.     (From  a  prepara- 

The  muscular  layer  is  double,  the  outer  tio^i  preserved  in  alcohol.) 

portion  being  composed  of  both  circular  and  spiral  fibers  mixed,  and 
the  inner  of  longitudinal  fibers  only,  and  these  two  layers  are  so 
closely  bound  together  by  the  cavernous  venous  sinuses  as  to  be  in 
reality  but  one.  Dr.  Ufileman  claims  to  have  found  an  additional 
external  layer,  the  fibers  of  which  are  voluntary.  He  divides  this 
layer  into  two — an  external  and  an  internal — the  former  longitud- 
inal, the  latter  transverse.  These  make  what  he  calls  the  outer  or 
voluntary  sphincter  of  the  bladder.  From  the  vesical  neck  to  a 
point  about  half-way  down  it  w^holly  invests  the  urethra,  forming 
only  a  partial  investment  from  that  point  to  the  meatus. 

Luschka  claims  to  have  found  a  sphincter  of  the  urethra  and 
vagina.  He  describes  it  as  being  smooth  and  circular,  from  one 
sixth  to  one  third  of  an  inch  broad,  lying  directly  behind  the  vesti- 
bule, and  girdling  both  the  vagina  and  urethra.  Its  function,  he 
says,  is  to  close  the  urethra  by  pressing  it  against  the  urethro-vagi- 
nal  septum.  Being  closely  adjacent  to  the  cavernous  venous  tissue 
of  the  urethra,  it  locks  its  fibers  posteriorly  with  those  of  the  mus- 
culus  transversus  profundus. 

In  the  female  as  in  the  male,  the  urethra  pierces  the  triangular 
subpubic  ligament,  two  layers  of  which  extend  around  it ;  one  back- 
ward and  the  other  foi'w^ard. 


668  DISEASES  OF  WOMEN. 

There  is  great  diversity  of  opinion  as  to  the  nature  of  the  vest 
cal  opening  of  the  nrethra  in  the  female.  Aeeording  to  Winckel 
and  Simon  it  is  a  diagonal  slit,  the  mucous  membrane  of  which  is 
longitudinally  and  superficially  corrugated.  According  to  Savage, 
it  is  a  triangular  opening ;  and  according  to  Holden  and  others,  a. 
funnel-shaped  opening.  It  of  course  varies  somewhat  with  age,  size 
of  urethra,  vesical  contraction,  or  quiescence,  and  in  the  living  and 
dead  subject ;  and  hence  the  diverse  opinions  of  the  various  ob- 
servers. 

Anatomical  Relations  of  the  Bladder  and  Urethra. — Having  dis- 
cussed the  anatomy  of  the  bladder  and  urethra,  it  remains  to  exam- 
ine the  topographical  relations  of  these  organs.  This  is  very  neces- 
sary to  a  proper  understanding  of  the  influence  of  other  organs  in 
causing  diseases  and  displacements  of  the  bladder  and  urethra. 

The  bladder  of  the  female  lies  lower  in  the  pelvis  than  that  of 
the  male,  between  the  pubes  anteriorly,  the  uterus  posteriorly,  the 
vagina  and  uterine  cervix  inferiorly,  and  the  small  intestines  superi- 
orly. The  organ  when  empty  lies  behind  the  symphysis  pubis,  its 
highest  point  slightly  overtopping  it.  In  this  position  it  occupies 
but  little  space.  When  partially  or  wholly  tilled  it  rises  above  the 
pubes  to  a  varying  extent.  In  doing  this  it  alters  but  slightly  the 
position  of  the  other  pelvic  viscera,  although  relatively  its  position 
is  somewhat  changed. 

Anteriorly  the  bladder  is  separated  from  the  posterior  face  of 
the  pubic  symphysis  by  intervening  cellular  tissue.  Inferiorly  it 
forms  a  close  attachment  to  the  anterior  vaginal  wall  by  means  of  a 
dense  celhilar  cushion  which  increases  in  thickness  from  before  back- 
ward. The  bladder  rests  upon  this  vesico- vaginal  septum  as  far  up 
as  the  point  where  the  body  and  neck  of  the  uterus  join  each  other. 
Posteriorly  and  somewhat  superiorly  to  the  bladder  lies  the  uterus^ 
and  superiorly  and  postero-laterally  are  the  ovaries  and  broad  liga- 
ments. 

The  close  attachment  of  the  vesical  neck  to  the  arch  of  the  pubes, 
by  the  pubic  ligament  anteriorly  and  the  vagina  inferiorly,  makes  a 
kind  of  wedge  that  gives  but  little  surface  for  bagging  downward 
if  the  vagina  holds  its  proper  position.  Though  imperfectly,  still  to 
a  certain  extent,  this  arrangement  resembles  the  perin?eum  in  the 
male.  Superiorly,  tlie  organ  is  held  in  position  by  a  number  of 
ligaments  ;  five  false  and  five  true.  The  false  ligaments  (one  supe- 
rior, two  lateral,  and  two  posterior),  are  formed  of  peritonaeum. 
This  membrane  is  reflected  from  the  inner  face  of  the  anterior  ab- 
dominal wall  to  the  bladder  investing  it  superiorly,  laterally,  and,  to 


RELATIONS   OF   THE   BLADDER   AND   URETHRA.  669 

a  certain  extent,  posteriorly.  It  joins  the  organ  in  front,  dipping 
down  just  above  the  pubic  summit  to  the  superior  vesical  surface, 
and  passes  as  far  backward  as  the  point  of  contact  between  the  vesi- 
cal base  and  uterus,  which  is  at  the  junction  of  the  uterine  body  and 
cervix.  Although  this  peritoneal  covering  of  the  bladder  is  hrmly 
adherent,  it  never  leaves  its  uterine  or  other  attachments,  however 
much  the  bladder  may  be  distended  and  rise  above  the  brim  of  the 
pelvis. 

That  portion  of  the  bladder  lying  behind  the  pubes,  that  resting 
on  the  vagina  and  uterine  neck,  and  a  small  posterior  and  lateral 
portion  have  no  serous  investment. 

The  true  ligaments  are  also  five  in  number — two  anterior  or 
vesico-pubic,  two  lateral,  and  the  superior  or  urachus  cord. 

Laterally,  the  round  ligaments  of  the  uterus  pass  over  the  blad- 
der-wall, and  just  below  and  posteriorly  the  ureters  enter  that 
organ. 

These  ducts,  the  excretory  ducts  of  the  kidneys,  are  usually  de- 
scribed as  passing  downward,  forward,  and  inward,  after  entering 
the  cavity  of  the  pelvis,  to  the  base  of  the  bladder,  and  after  passing 
for  an  inch  between  the  muscular  coats  of  that  organ  opening  into 
it  by  constricted  orifices.  In  their  course  they  pass  along  the  sides 
of  the  cervix  uteri  and  upper  part  of  the  vagina,  and  at  their  points 
of  entrance  into  the  bladder  are  from  one  half  to  three  quarters  of  an 
inch  in  front  of  the  cervix  uteri.  It  is  very  important  that  the  re- 
lation of  the  ureters  to  the  bladder  should  be  borne  in  mind,  espe- 
cially in  the  operation  of  gastro-elytrotomy.  Garrigues,  who  has  in- 
vestigated this  point,  says :  "  The  ureter  does  not  lie  in  the  broad  liga- 
ments, it  does  not  keep  the  same  direction  on  reaching  the  wall  of 
the  bladder,  and  it  does  not  lie  close  up  to  the  wall  of  the  cervix,  as 
taught  by  anatomical  authorities.  After  having  crossed  the  iliac 
vessels  the  ureters  diverge,  running  downw'ard,  backward,  and  a  lit- 
tle outward  on  the  wall  of  the  pelvis,  behind  the  broad  ligaments  to 
a  point  near  the  spina  ischii.  Then  they  lead  downward,  forward, 
and  considerably  inward  so  as  to  converge  toward  the  bladder.  They 
pass  beneath  the  base  of  the  broad  ligament,  lying  in  the  abundant 
cellular  tissue  found  in  this  locality.  They  cross  the  cervix  at  some 
distance  from  behind,  at  an  acute  angle,  so  as  to  come  in  front  of 
and  below  it.  They  lie  outside  and  above  the  anterior  part  of  the 
side  wall  of  the  vagina  on  a  spot  as  large  as  the  tip  of  the  finger. 
On  reaching  the  wall  of  the  bladder  they  turn  rather  sharply  inward 
and  go  downward  until  they  open  with  a  small  slit  into  the  inte- 
rior of  the  bladder  at  the  outer  angle  of  the  trigonum  vesica.     But 


670 


KELATIONS  OF  THE  BLADDER  AND  URETHRA. 


on  dissecting  the  bladder  from  the  utenis  and  vagina  their  substance 
is  seen  to  continue  as  a  solid  ridge  between  the  two  apertures,  and 
forming  the  base  of  the  trigone  (Jurie's  inter-ureteric  ligament.)  " 

The  illustration  of  Gar- 
rigues  makes  this  descrip- 
tion very  clear  (Fig.  24-5.) 
Just  in  front  of  the 
small  lateral  space  lacking 
serous  investment  the  ob- 
literated umbihcal  arteries 
pass  upward  and  forward 
to  the  summit  of  the  blad- 
der reflecting  the  perito- 
nteum,  and  thus  forming 
a  double  pouch  on  eitlier 
side. 

The  relations  of  the 
urethra  are  as  follows :  it 
lies  just  under  the  pubic 
symphysis,  and,  piercing 
the  deep  perineal  fascia, 
extends  from  the  vesical 
neck,  at  the  ostium  ure- 
thrte  internum,  to  the  meatus  urinarius  or  ostium  urethrse  externum, 
situate  at  the  base  of  the  triangular  space  known  as  the  vestibule. 
Its  anterior  three  fourths  are  imbedded  in  the  vaginal  wall.  The 
meatus  urinarius  lies  about  four  fifths  of  an  inch  below  the  clitoris, 
in  the  vaginal  margin  of  the  vestibule.  The  vesical  end  of  the 
urethra  is  about  the  same  distance  below  the  lower  surface  of  the 
pubic  symphysis.  Its  course  is  upward  and  backward  forming  a 
very  sliglit  curve. 

Development  of  the  Bladder  and  Urethra. — With  this  brief  sketch 
of  the  structure  of  the  bladder  and  urethra  their  development  may 
be  next  considered.  It  would  be  very  interesting,  from  a  scientific 
point  of  view,  to  examine  the  process  by  which  the  bladder  and 
urethra  are  formed  in  the  embryo  ;  but  it  would,  I  think,  be  rather 
tedious  to  take  up  the  subject  in  all  its  minutiae.  A  few  of  the 
more  important  points  in  the  process  of  development  must  be  un- 
derstood, however,  in  order  to  comprehend  the  malformations  Avhich 
are  occasionally  met  with.  Most,  or  at  least  many,  of  the  malfor- 
mations of  the  urinary  apparatus,  like  those  of  other  organs  are  due 
to  arrest  of  development  at  various  stages  of  that  process.     A  clear 


Fig.  245. — The  relations  of  the  ureters  (Garrigues). 
u,  uterus  ;  b,  bladder ;  ur,  ureter  ;  u,  urethra ; 
V,  vagina ;  f,  Fallopian  tube ;  o,  ovary  ;  b,  broad 
ligament ;  r,  round  ligament. 


DEVELOPMENT   OF   THE    BLADDER   AND    URETHRA.         G71 

conception  of  the  normal,  therefore,  will  aid  in  better  understanding 
the  abnormal. 

The  urinary  organs  are  develojjed  in  separate  portions  or  sec- 
tions having  distinct  points  of  origin,  and  by  the  union  and  fusion 
of  these  parts  the  entire  apparatus  is  completed. 

The  bladder  is  formed  from  a  portion  of  the  allantois.  When 
the  abdominal  plates  of  the  embryo  close  around  that  portion  of  the 
allantois  that  forms  the  umbilical  cord,  they  also  shut  in  a  j)ortion 
which  fonns  the  urinary  bladder.  There  remains,  for  a  time,  a  di- 
rect communication  between  that  portion  of  the  allantois  from  which 
the  bladder  is  formed  and  that  which  makes  the  cord,  which  takes 
the  name  of  the  urachus.  The  canal  or  duct  in  the  urachus  is  usu- 
ally obliterated  before  or  soon  after  birth,  so  that  all  that  remains  of 
it  is  an  impervious  cord  known  as  the  superior  vesical  ligament.  It 
will  thus  be  seen  that  the  bladder  is  developed  from  the  allantois, 
which  may  be  called  one  center  of  development  for  the  urinary  ap- 
paratus. 

The  centers  of  development  for  the  ureters  are  the  same  as  those 
for  the  kidneys.  Indeed,  the  ureters  are  processes  that  are  developed 
from  the  kidneys,  and  extend  downward  until  they  unite  with  the 
bladder,  and  finally  open  into  it. 

While  the  bladder  and  ureters  are  being  thus  formed,  the  lower 
portion  of  the  alimentary  canal — that  which  forms  the  rectum — be- 
comes separated  from  the  section  of  the  allantois  that  forms  the 
bladder.  Into  this  space,  between  the  rectum  and  bladder,  Miiller's 
ducts  descend,  and,  uniting,  form  the  vagina  (see  Figs.  53-57). 

Posterior  to  Miiller's  ducts  and  anterior  to  the  rectum,  a  mass  of 
tissue  is  developed  which  helps  to  form  the  recto- vaginal  wall  above 
and  the  periugeum  below. 

Anteriorly  Miiller's  ducts  unite  with  the  lower  portion  of  the 
bladder,  and  aid  in  the  formation  of  the  urethra,  or,  at  least,  the  up- 
per portion  of  its  posterior  wall. 

The  lower  or  external  portions  of  the  genito-urinary  organs  are 
formed  from  an  ovoid  eminence  which  appears  in  the  median  line 
of  the  lower  anterior  part  of  the  trunk  of  the  embryo.  At  the  lower 
part  of  this  eminence  there  appears  a  fissure,  which,  incurvating  and 
uniting  with  tlie  lower  portion  of  Miiller's  ducts  (vagina)  forms  the 
terminal  portion  of  the  urethra  and  the  introitus  vaginae.  From  this 
same  center  of  development  the  labia  majora,  the  labia  minora,  and 
the  vestibule  are  formed. 


CHAPTER  XXXYII. 

MALFORMATIONS    OF   THE   BLADDER   AND    URETHRA. 

Malformations  of  the  Urethra. — Malformatioiis,  as  has  already  been 
said,  are  usually  the  result  of  arrested  develoi3ment.  Yarious  fail- 
ures in  the  processes  necessary  to  form  the  complete  urethra  result 
in  a  number  of  malformations.  The  most  important  of  these  may 
be  classified  as  follows  : 

1.  Defectus  urethras  totalis. 

2.  Defectus  urethrse  externus. 

3.  Defectus  urethra3  internus. 

4.  Atresia  urethrfe. 

In  the  first  form  (defectus  urethrse  tofalis)  there  is,  as  the  term 
implies,  entire  absence  of  the  urethra.  It  is  said  to  be  due  chiefly 
to  an  arrest  in  the  development  of  the  vagina  at  a  point  where  it 
should  form  the  main  portion  of  the  posterior  wall  of  the  urethra. 
It  is  very  probable  that  there  is  also  an  arrest  of  development  of 
the  clitoral  process. 

Coexisting  with  this  malformation  other  developmental  defects 
are  generally  but  not  invariably  found,  for  it  has  been  known  to  exist 
with  an  otherwise  perfect  genito-urinary  apparatus.  Petit  tells  of  the 
case  of  a  child,  four  years  old,  who  had  neither  urethra,  clitoris,  nor 
nymphfe,  but  had  a  comparatively  wide  vagina.  Langenbeck  men- 
tions the  case  of  a  girl,  nineteen  years  of  age,  in  whom  the  bladder 
and  vagina  formed  a  common  canal.  She  was  incontinent  up  to  the 
age  mentioned,  and  is  reported  to  have  gained  control  of  the  bladder 
afterward. 

The  second  deformity  (defectus  urethrae  externus)  is  due  to  the 
absence  of  the  lower  and  anterior  portion  of  the  urethra.  It  has 
been  called  "  hypospadias  in  the  female."  One  of  the  most  marked 
cases  has  been  recorded  by  Von  Mosengeil.  The  subject  was  a  girl 
eight  years  old.  The  opening  in  the  urethra  was  situated  below  a 
large  clitoris,  having  a  very  full  prepuce.     It  was  much  higher  than 

672 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   673 

the  normal  situation  of  the  meatus  urinarius.  There  was  a  groove 
running  from  the  lower  border  of  the  vestibule  up  to  the  opening  of 
the  urethra,  and  it  appeared  to  be  formed  from  the  anterior  wall  of 
the  urethra.  The  upper  portion  of  the  urethra  held  its  normal  rela- 
tions to  the  bladder  and  vagina,  but  was  only  half  an  inch  in  length. 
The  bladder,  in  comparison  with  the  other  organs,  was  larger,  and 
had  a  number  of  sacculae.  It  will  be  observed  that  in  this  case 
the  upper  portion  of  the  urethra  was  complete,  and  that  there  were 
present  in  the  lower  portion  of  the  canal  an  anterior  and  two  rudi- 
mentary lateral  walls,  the  posterior  wall  alone  being  absent. 

There  is  another  form  of  defectus  urethrse  extemus  or  hypos- 
padias, in  which  the  lower  part  of  the  canal  is  entirely  wanting.  In 
such  cases  there  is  but  one  opening  between  the  clitoris  and  peri- 
nseum,  and  but  one  canal,  this  dividing  into  vagina  and  urethra  at 
some  distance  from  the  outer  opening.  An  interesting  example  of 
this  was  observed  by  Willigk,  in  a  woman,  who  died  at  the  age  of 
forty-six.  The  uro-genital  canal,  at  its  opening,  was  about  the  size 
of  a  catheter,  and  ran  in  a  curved  direction  under  the  pubes.  About 
an  inch  and  a  half  from  its  outer  opening  it  divided  into  two  pass- 
ages, one  anteriorly,  V  long — the  urethra,  and  one  posteriorly,  2" 
to  10''  long — the  vagina. 

The  third  defonnity  (defectus  urethrse  internus)  is  that  in  which 
the  internal  or  upper  portion  of  the  urethra  is  wanting,  and  is  a 
comparatively  rare  affection.  The  only  cases,  so  far  as  I  know,  are 
given  by  Oberteufer  and  Duparcque.  In  Oberteufer's  case,  as  I 
understand  it,  the  lady  was  forty-two  years  of  age,  and  all  her  life 
had  passed  water  from  the  umbilicus.  Her  vagina  was  normal,  and 
so  were  the  external  genital  organs.  The  upper  or  internal  portion 
of  the  urethra  alone  was  wanting.  Duparcque's  case  was  one  in 
which  the  urethra  was  pervious  as  far  as  the  bladder,  but  was  there 
closed.  This  case,  however,  appears  to  me  more  properly  to  come 
under  the  head  of  atresia  urethrse. 

The  fourth  class  (atresia  urethrse)  is  a  comparatively  common 
affection.  There  are  two  forms  of  congenital  atresia  mentioned  by 
authors.  The  first  is  produced  by  imperfect  development  of  the 
vaginal  process,  or  of  both  the  clitoral  and  vaginal  segments.  Du- 
parcque's case  was  of  this  kind,  the  urethra  being  open  up  to  the 
bladder  and  there  closed.  It  was  a  form  of  defectus  urethriB  in- 
ternus with  atresia  at  the  upper  end  of  the  canal.  In  this  case  the 
bladder  and  ureters  were  greatly  distended. 

The  other  form  of  atresia  is  found  when  the  clitoral  and  vagi- 
nal processes  are  both  defective.  In  such  cases  there  is  no  trace  of 
44 


674  DISEASES  OF   WOMEN. 

a  urethra,  except  an  imperfect  vaginal  wall  which  extends  obliquely 
downward  and  closes  the  bladder.  E.  Rose  relates  a  case  of  this 
kind  in  which  the  bladder,  kidneys,  and  abdomen  were  filled  with 
water.  The  urethral  malformation  was  not  the  only  one  in  this  case, 
the  vagina  and  uterus  suffered  from  an  arrest  of  development  and 
were  both  double  or  rudimentary. 

Before  leaving  this  interesting  subject  I  will  mention  another 
rare  malformation.  It  is  an  obstructive  anomaly,  and  consists  in  a 
double  condition  of  the  urethra.  The  only  case,  so  far  as  I  know, 
which  has  been  described  with  any  accuracy,  is  that  of  Furst.  He 
observed  in  a  preparation  taken  from  the  body  of  a  young  virgin  the 
following  peculiarities  :  In  looking  at  the  anterior  bladder- wall  at 
the  first  glance  only  one  urethral  orifice  was  to  be  seen,  but  one 
tenth  of  an  inch  forward  toward  the  meatus  the  single  urethra  was 
seen  to  bifurcate ;  a  fine  septum,  nearly  straight,  divided  it  from 
right  to  left  into  an  anterior  and  posterior  half ;  these  continued 
with  an  ever  enlarging  and  diverging  septum  until  they  opened  into 
the  vagina  about  one  tenth  of  an  inch  apart.  In  this  way  they 
twisted,  so  that  the  anterior  or  superior  one  opened  toward  the  right, 
while  the  posterior  (the  one  in  the  region  of  the  bladder)  opened 
into  the  vagina  on  the  left.  The  left  urethra  opened  with  a  caliber 
of  one  fifth  of  an  inch  into  the  median  line  of  the  vagina.  The  right 
opened  on  the  right  of  the  median  line,  having  a  caliber  of  only  one 
tenth  of  an  inch.     The  length  of  the  w^hole  urethra  was  one  inch. 

It  is  of  very  rare  occurrence  that  the  double  condition  of  the 
allantois  persists  in  this  manner,  and,  considering  all  the  changes 
that  the  sinus  uro-genitalis  has  to  undergo,  it  seems  strange  that 
blending  did  not  take  place.  It  is  also  interesting  from  the  fact 
that  the  allantoic  openings  into  the  cloaca  can  only  take  place  by  a 
very  rapid  and  early  interruption  of  development.  The  uterus  and 
vagina,  in  this  case,  were  perfectly  normal. 

Symptomatology  of  Malformation  of  the  Urethra. — The  symptoms 
that  arise  from  malformation  of  the  urethra  are  incontinence  in  the 
one  class  of  cases,  and  retention  of  urine  in  the  other.  When  the 
urethra  is  deficient  in  part  and  the  bladder  perforate,  urine  con- 
stantly escapes  ;  and  from  the  wetting,  the  excoriation,  and  the  odor, 
the  unfortunate  subject  is  kept  in  continual  misery. 

In  cases  where  there  is  an  abnormal  contraction  of  the  vagina 
the  urine  can  be  retained,  partially  at  least.  This  is  supposed  to  be 
effected  by  the  small  size  of  the  genito-urinary  sinus,  and,  possibly, 
a  voluntary  contraction  of  the  sphincter  vagina  muscle  which  may 
act  as  a  sort  of  sphincter  and  aid  in  the  retention  of  urine. 


MALFORMATIONS   OF   THE    BLADDER   AND    URETHRA.      675 

Atresia  of  the  urethra  and  the  consequent  retention  of  tlie  urine 
cause  hydrops  of  the  bladder,  ureters,  and  kidneys,  and  also  ascites, 
as  has  already  been  mentioned.  Distention  of  these  organs  occurs 
in  utero,  and  such  malformed  children  are  usually  born  dead,  or  die 
soon  after  birth.  So  great  is  this  distention  of  the  bladder  and  ab- 
domen in  some  cases  that  delivery  is  difficult  or  impossible  until 
the  fluid  is  evacuated  by  puncture.  I  remember  seeing  one  such 
case.  The  head  was  delivered,  but  there  was  great  difficulty  in  de- 
livering the  body.  The  abdomen  was  enormously  enlarged  by  the 
overdistention  of  the  urinary  organs.  The  child  was  very  feeble, 
and  after  moaning  for  a  few  hours,  died.  ISTo  efEort  to  relieve  the 
bladder  was  made  because  a  diagnosis  was  not  reached  until  the  lit- 
tle one  was  dead. 

This  malformation  usually  leads  to  fatal  results,  and  our  knowl- 
edge avails  us  little  save  in  accounting  correctly  for  the  cause  of 
death.  The  only  natural  way  that  the  evil  effects  of  this  malforma- 
tion can  be  obviated  is  by  the  occurrence  of  another  developmental 
anomaly,  viz.,  fistula  of  the  urachus,  the  urine  then  escaping  from 
the  umbilicus.  Atresia  is  an  undoubted  factor  in  the  production  of 
urachal  fistula.  I  shall  speak  more  fully  of  this  when  I  come  to 
consider  vesical  malformations. 

When  defectus  urethrse  externus  occurs  in  patients  whose  uro- 
genitals are  otherwise  normal,  the  function  of  the  bladder  and  re- 
productive organs  may  all  be  performed  easily  and  uninterruptedly. 
Coitus  has  been  possible,  and  conception  has  been  known  to  occur 
in  such  cases. 

Diagnosis. — In  making  a  diagnosis  of  these  deformities  reliance 
can  not  be  placed  on  the  symptoms  alone.  A  physical  examination 
of  the  parts  is  necessary.  The  general  relative  apjDcarance  of  the 
external  organs  must  be  observed,  and  if  the  vagina  is  large  enough, 
to  admit  the  speculum  it  should  be  used,  and  if  there  is  any  malfor- 
mation internally  it  can  easily  be  discovered  and  its  exact  location 
and  nature  ascertained.  There  is  usually  very  little  trouble  with 
such  cases,  but  where  the  entrance  to  the  vagina  is  so  narrow  that 
it  will  not  admit  a  sound  or  speculum,  tbe  diagnostic  skill  of  the 
physician  will  be  severely  taxed.  Such  cases  resemble  imperforate 
hymen,  or  acquired  atresia  of  the  vulva,  and  one  case,  at  least,  has 
been  mistaken  for  an  hermaphrodite.  Under  such  circumstances  an 
attempt  should  be  made  to  pass  the  sound  into  the  bladder,  and  by 
introducing  the  finger  or  another  sound  into  the  rectum  the  pres- 
ence or  absence  of  a  vagina  may  possibly  be  made  out.  If  the 
patient  is  an  adult,  and  the  case  one  of  imperforate  h}Tnen,  men- 


676  DISEASES  OF   WOMEN. 

Gtrual  fluid  will  probably  be  found  in  the  vagina.  Should  there  still 
remain  any  doubt,  the  only  resource  would  be  to  try  dilatation  of 
the  introitus  vaginae,  and  see  what  lies  beyond  it. 

Treatment. — The  treatment  may  be  either  radical  or  palliative. 
Where  there  is  an  entire  absence  of  the  urethra,  with  the  existence 
of  vesical  fissure,  or  in  persistence  of  the  sinus  uro-genitalis  with 
partially  developed  urethra,  the  production  of  an  artificial  canal  has 
been  suggested.  This  may  be  done  by  dissecting  from  the  vaginal 
wall  a  flap  from  under  the  symphysis.  It  should  be  about  one  third 
of  an  inch  in  breadth,  and  after  being  turned  with  its  epithelial  sur- 
face inward,  should  be  united  with  the  freshened  edges  of  the  vesi- 
cal fissure.  It  is  objected  by  some  authors  that  even  if  the  opera- 
tion is  successful,  the  patient  will  be  but  little  benefited,  the  new 
urethra  being  devoid  of  muscular  tissue,  and  consequently  lacking 
the  power  of  contraction.  The  passing  of  urine  into  the  vagina, 
however,  will  be  done  away  with,  and  the  general  condition  of  the 
patient  will  be  greatly  improved  by  the  use  of  an  artificial  urinal. 
This  of  itself  is  a  great  point  in  favor  of  the  operation. 

Heppner  beheves  that  the  method  of  producing  an  artificial  ure- 
thra by  trocar  puncture  of  the  soft  tissues  and  sewing  up  the  vesical 
fissure  is  dangerous,  because  vessels  of  considerable  size  are  liable 
to  be  injured ;  a  further  disadvantage  being  that  the  canal  tends  to 
close.  The  cases  of  Carbol  and  Middleton  bearing  on  this  point  he 
puts  aside  as  unreliable.  He  moreover  maintains  that  reduction  of 
the  vesical  fissure  to  the  size  of  the  urethra  is  a  disadvantage,  since 
the  anterior  wall  of  the  fissure  will  be  without  any  muscular  tissue. 
The  experience  of  those  who  have  treated  fistula  has  been,  so  far  as 
he  knows,  that  linear  clefts,  even  of  greater  caliber,  hold  back  the 
urine  better  than  round  openings  of  smaller  size,  the  former  allow- 
ing more  complete  coaptation  of  the  edges. 

In  Ileppner's  case,  there  being  only  nocturnal  incontinence,  he 
contented  himself  with  applying  a  bandage  in  the  manner  suggested 
by  Sawostitzki.  A  girdle  was  put  around  the  lower  part  of  tlte  ab- 
domen, and  to  it  was  fastened  a  little  olive-shaped  compress,  by 
means  of  a  steel  spring,  something  after  the  manner  of  a  truss. 
When  put  into  the  vagina  this  compress  pushed  the  posterior  vesi- 
cal wall  toward  the  pubic  symphysis,  thus  closing  the  opening  and 
relieving  the  incontinence.  The  patient  soon  became  used  to  the 
instrument,  and  obtained  great  relief  from  it. 

Atresia  of  the  urethra  can  only  be  cured  by  operation.  Carbol 
operated  in  1550  on  a  servant-girl  in  Beaucaire,  who  had  suffered 
from  this  difficulty  from  her  youth  up.     The  urine  flowed  from  a 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   6Y7 

coxcorab-like  growth,  some  four  fingers  in  length,  at  the  umbilicus. 
The  stench  that  arose  from  her  body  was  intolerable.  Carbol  per- 
forated in  the  region  of  the  urethra,  and  successfully  removed  the 
growth  at  the  umbilicus  by  ligation. 

In  the  case  of  a  child,  seven  days  old,  who  had  never  passed 
urine,  and  whose  bladder  was  enormously  distended,  Middleton 
pushed  a  trocar  through  in  the  direction  of  the  absent  urethra, 
emptied  the  bladder,  and  kept  the  opening  pervious. 

Oberteufer's  patient,  who  had  atresia  urethrse  and  urachal  fistula, 
relieved  herself  somewhat  by  wearing  a  large  sponge  over  the  um- 
bilicus secured  in  position  by  a  bandage.  In  such  cases  as  this  the 
apparatus  usually  employed  in  urinary  fistula  should  be  made  use  of. 


MALFORMATIONS    OF    THE    BLADDER. 

These  malformations  follow  the  general  rule  of  being  in  most  in- 
stances due  to  some  defect  in  the  normal  process  of  development. 
Those  which  are  of  sufficient  importance  and  especially  demand  atten- 
tion are : 

1.  Fissure. — The  most  frequent  and  prominent  anomaly  of  devel- 
opment in  the  bladder  is  that  of  fissure.  It  consists  in  partial  or 
complete  absence  of  the  anterior  vesical  wall,  and  is  usually  accom- 
panied by  malformations  of  other  organs.  The  anus  and  umbilicus 
in  these  cases,  as  a  rule,  lie  nearer  than  normal  to  the  pubic  symphy- 
sis. 

There  are  various  grades  of  this  affection.  There  may  be  sim- 
ple fissure  of  the  lower  part  of  the  bladder,  with  the  opening  about 
three  quarters  of  an  inch  in  breadth,  as  has  been  seen  by  Desault, 
Palletta,  Gosselin,  Coates,  and  others.  In  the  cases  reported  by 
them  the  symphysis  pubis  was  but  loosely  united.  There  may  also 
be  fissure  of  the  clitoris. 

A  higher  grade  of  this  malformation  is  that  in  which  the  fissure 
is  near  the  umbilicus,  the  lower  part  of  the  pelvic  cavity  and  the 
pubic  symphysis  being  closed,  and  the  lower  part  of  the  bladder, 
urethra,  and  external  genitals  normal.  This  condition  is  next  in 
order  to  patency  of  the  urachus — fistula-vesico-umbilicalis.  In  the 
latter  case,  the  urachus  may  remain  pervious  its  entire  length,  and 
open  into  the  ring  of  the  umbilicus. 

The  highest  grade  is  that  in  which  the  whole  anterior  wall  of  the 
bladder  seems  to  be  absent.  In  these  cases  the  inferior  abdominal 
region  is  generally  much  shorter,  and  the  umbilicus  nearer  the  base 
of  the  pelvis.     The  abdominal  walls  are  divided,  and  the  resultant 


678  DISEASES  OF  WOMEN. 

fissure  "is  filled  up  by  tlie  bladder-wall,  the  mucous  membrane  of 
wbicli  is  putted  out  and  red,  and  gradually  merges  into  the  skin  of 
the  abdomen.  It  is  often  wrinkled,  thickened,  moist,  shiny,  and  the 
edges  dry  and  covered  with  thickened  epidermis. 

On  each  side  of  the  lower  portion  of  the  evei-ted  bladder  are  situ- 
ated the  orifices  of  the  ureters.  They  usually  appear  as  little  ex- 
crescences, but  are  sometimes  hidden  in  the  folds  of  the  membrane. 
The  pubic  bones  are  imperfectly  developed,  and  the  pubic  symphy- 
sis never  closed,  save  by  a  ligamentous  band,  the  bones  lying  from 
half  an  inch  to  three  inches  apart.  These  separations  of  the  pubic 
bones,  as  has  been  shown  by  Dubois,  Dupuytren,  Mery,  and  Littre, 
are  congenital. 

As  a  rule,  in  such  cases,  the  urethra  is  absent.  The  clitoris  is 
either  divided  with  a  portion  on  each  side  of  the  upper  part  of  the 
imperfectly  formed  labia,  or  there  may  remain  but  a  trace  of  it,  or, 
again,  it  may  be  entirely  absent.  The  hymen  can  be  seen  beneath 
the  fissure.  The  vagina  may  be  absent,  as  in  cases  observed  by 
Herder  and  Eschenbach,  and  the  uterus  may  be  divided  by  a  septum. 
Atresia  vaginae  and  imperfect  ovaries  have  also  been  found  in  such 
cases.     This  grade  is  known  as  eversio  or  exstropia  vesicae. 

If  there  is  simply  a  fissure  of  the  bladder  the  organ  may  be  pro- 
lapsed through  the  fissure  (inversio  vesicae  cum  prolapsu  per  fis- 
suram).  This  must  be  distinguished  from  inversio  vesicae  cum  pro- 
lapsu per  urethram  and  exstropia  per  urachura.  That  this  may  be 
clearly  understood,  it  must  be  remembered  that  inversion  of  the 
bladder  occurs  in  three  ways :  First,  by  a  protrusion  of  the  organ 
through  an  opening  or  fissure  in  its  own  Avails  (the  form  now  under 
discussion) ;  second,  by  an  inversion  through  the  urethra ;  and  third, 
by  an  inversion  through  a  pervious  urachus. 

The  ureters,  as  a  rule,  are  considerably  widened.  Isenflamm 
found  them  dilated  from  three  quarters  of  an  inch  to  more  than  an 
inch  ;  Petit  as  much  as  two  inches  ;  Flagani  and  Bailie  found  them 
to  be  four  inches ;  Desault  three  inches ;  and  Littre  two  and  one 
half  inches,  and  containing  small  calculi.  Their  course,  as  a  rule,  is 
changed,  sinking  dee])er  into  the  pelvis,  and  thence  rising  up  into 
the  bladder.  There  are,  however,  exceptions  to  their  enlargement. 
Bonn,  in  one  case,  observed  as  long  ago  as  in  1818,  found  their  length 
and  breadth  normal.  Winckel  also  speaks  of  a  case  where  both  kid- 
neys and  ureters  were  normal. 

The  anomalies  known  as  epi-  and  ana-spadias  belong  under  the 
head  of  vesical  fissures. 

2.  Double  Bladder. — Cases  of  double  bladder,  says  Voss,  are  be- 


MALFORMATIONS  OF  THE  BLADUER  AND  URETHRA.   679 

coming  quite  rare  as  patliological  knowledge  advances,  for  many 
of  these  were  probably  cases  of  pathological  division  of  the  vaginal 
wall. 

Mollinetti  mentions,  in  his  ''  Anatomico-Pathological  Disserta- 
tions," the  case  of  a  woman  with  five  bladders,  live  kidneys,  and  six 
ureters.  Blasius  describes  a  case  of  perfect  division  of  the  bladder 
into  two  separate  halves,  which  at  the  vesical  neck  ended  in  one 
common  m-ethra.  Each  bladder  had  one  ureter.  The  subject  was  a 
male  adult.  Isaac  Cattier  has  found  this  anomaly  in  little  children. 
One  case  was  that  of  a  child  fifteen  days  old.  The  bladders  were 
separated  by  the  rectum  to  such  a  degree  that  a  finger  could  be  laid 
between  them.  Sommering  found  this  condition  in  a  child  two 
months  old.  In  one  that  was  born  miserably  nourished,  and  lived 
but  twelve  hours,  Schatz  found  perfect  division  of  the  whole  geni- 
tal apparatus,  double  bladder,  and  double  congenital  vesico-vaginal 
fistula.  In  double  bladder,  the  double  allantois,  instead  of  forming 
one  passage,  forms  two,  with  a  ureter  opening  into  each. 

Testa  gives  a  case  of  perfect  separation  by  the  vaginal  wall. 
Scanzoni  found,  in  making  a  post-mortem  examination  on  the  body 
of  a  tuberculous  woman,  a  division  of  the  bladder  into  two  lateral 
halves.  He  does  not  say,  however,  whether  the  division  was  com- 
plete or  whether  the  septum  was  pervious. 

Sometimes  horizontal  septa  are  formed  that  are  due  probably  to 
a  crumpling  up  of  a  part  of  the  bladder  while  growing,  or  a  com- 
mencing closure  of  the  urachus  lower  down  than  usual. 

Roser,  of  Marburg,  had  a  case  of  urachal  cyst,  which,  when 
enormously  distended,  reached  as  far  as  the  umbilicus.  By  means 
of  a  small  connection  with  the  bladder  it  was  filled  when  that  organ 
contracted,  and,  finally,  it  and  the  bladder  were  emptied  by  contrac- 
tion of  the  abdominal  muscles.  Yesical  cysts  and  diverticula  may 
be  confounded  with  the  anomalies  resulting  from  arrest  of  devel- 
opment. 

The  slightest  grade  of  anomaly  is  that  in  which,  as  Chonsky  has 
observed,  there  is  no  full  septum,  but  simply  a  band  or  seam,  appar- 
ent externally. 

Etiology. — The  original  urinary  sac  of  the  embryo,  it  will  be 
remembered,  is  the  allantois,  which  takes  its  origin  as  a  cul-de-sac 
from  the  rectum,  and  is,  consequently,  an  offshoot  of  the  intestine. 
It  is  foi'med  by  the  ba2:2;in2::  of  the  cloaca,  which  baffS'ino;  is  due  to 
the  collection  there  of  urine  from  the  primitive  kidneys.  This  allan- 
tois, especially  in  the  human  species,  is  double,  and  remains  only  a 
short  time.     After  the  fourth  week  of  embryonic  life,  the  layei*s 


680  DISEASES  OF  WOMEN. 

coalesce,  and  the  division  ceases.  Yet  the  original  double  form  may 
remain  for  some  time  beyond  the  normal  period,  if  there  are  anv 
hindrances  to  union. 

Roose  and  Creve  maintain  that  the  cause  of  this  malformation  is 
the  failure  of  the  pubic  bones  to  unite.  Meckel  takes  exception  to 
tliis,  and  says  that  the  bladder  in  its  primitive  condition  shows  itself 
as  a  simple,  plain  sm-face,  which  only  becomes  a  cavity  by  the  grow- 
ing toward  each  other  and  union  of  its  edges.  Dimcan  and,  at  a 
later  date,  A.  Bonn,  and,  still  later,  B.  S.  Schultze-  and  Thiersch, 
held  that  vesical  fissure  had,  as  its  primary  cause,  an  atresia  of  the 
urethra,  with  great  dilatation  of  the  bladder,  the  distended  organ 
pushing  aside,  iirst,  the  recti  muscles,  later,  the  cartilaginous  pubic 
bones,  and,  iinally,  bursting.  E.  Rose,  on  the  contrary,  maintains 
that  these  cases  of  bladder-lissure  are  cases  of  perpetuated  urachus, 
and  are  due  to  developmental  failure  in  the  bladder  itself,  remain- 
ing open  as  far  as  the  urethra.  He  says  positively  that  the  edges  of 
recent  preparations  of  the  bladder  show  a  fresh,  smooth  surface,  and 
that  there  is  no  trace  whatever  of  any  cicatrix  or  callosity.  He 
mentions  one  case  of  tearing  and  rupture  where  the  evidences  were 
plainly  to  be  seen.  Moergelin,  who  was  unable  to  find  proof  of 
rupture  as  a  cause  of  this  anomaly,  says  that,  if  there  was  a  quan- 
tity of  urine  in  the  bladder,  greatly  distending  it,  there  would  be 
a  reopening  of  the  urachus  or  a  bursting  into  the  abdominal  cavity, 
rather  than  a  rupture  through  the  abdominal  walls.  He  looks  favor- 
ably on  the  idea  of  a  bursting  of  the  allantois  before  the  abdominal 
walls  have  closed  in  front  of  it. 

Against  this,  however,  is  the  fact  that  Hecker  extracted  a  foetus 
with  atresia,  having  an  enormously  dilated,  unruptured  bladder.  He 
found  in  the  abdominal  walls  a  cicatrized  slit  covered  by  perito- 
naeum. This  makes  manifest  the  possibility  of  a  rupture  of  the  ab- 
dominal walls,  and  also  of  the  bladder,  occurring  at  a  comparatively 
late  date. 

In  the  case  related  by  Rose  no  information  is  given  as  to  whether 
there  was  a  normal  umbilical  cord  or  not,  whether  there  was  any 
urachal  fistula,  whether  the  abdominal  ring  was  closed  entirely,  or 
whether  the  fissure  was  confined  to  the  inferior  part  of  the  anterior 
vesical  wall,  as  described  by  Gosselin,  Bertet,  and  others.  In  their 
cases  it  was  not  possible  for  the  fissure  to  have  originated  by  the  re- 
opening of  the  urachus.  In  any  event,  most  of  the  late  authors  are 
agreed  that  hindrance  to  the  outflow  of  urine  has  most  to  do  with  the 
production  of  this  anomaly,  and  it  may,  as  Rose  has  shown,  and  as  has 
been  said  before,  arise  from  atresia  or  absolute  absence  of  the  urethra. 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   681 

Another  possible  mode  of  causation  of  this  malformation  is  bv 
the  falling  of  some  of  the  larger  abdominal  organs  into  the  pelvic 
cavity,  compressing  the  m-ethra,  and  hindering  its  formation.  E. 
Rose  once  found  the  right  kidney  in  the  pelvis,  and  Winckel  has 
recorded  a  case  described  by  one  of  his  students,  Dr.  Kriiger,  where 
the  left  lobe  of  a  considerably  enlarged  liver  and  a  quantity  of  small 
intestines  were  so  tightly  wedged  into  the  pelvis  as  to  cause  marked 
bulging  of  the  perinoeum.  Such  a  condition,  coming  at  a  time 
when  the  urachus  and  urethral  end  of  the  bladder  are  hrmly  closed, 
must  tend  to  form  a  vesical  fissure. 

Perfect  eversion  of  the  bladder  may,  however,  be  found  at  a  very 
early  date,  even  before  the  two  halves  of  the  allantois  are  joined,  as 
in  cases  related  by  Friedlander,  E.  Rose,  and  Winckel.  Lying  be- 
tween, and  in  front  of  the  single-  or  double-everted  bladder  or  blad- 
ders, there  are  sometimes  found,  as  in  Rose's  and  Winckel's  cases, 
bands  of  perforated  skin-folds,  behind  which  a  sound  may  be  passed. 
Their  presence  may  be  explained  in  this  way :  That  the  underlying 
serous  connective  tissue  (Rathke's  membrana  reuniens  inferior), 
which  closes  the  abdominal  cavity  before  the  development  of  the 
skin  and  muscular  system,  is  the  covering  of  all  urachal  fistul^e,  open 
bladders,  and  persistent  allantois.  Then,  where  the  urine  pressure 
is  the  greatest,  the  bladders  move  upon  each  other,  so  that  no  further 
development  can  take  place  between  them  ;  but  the  abdominal  plates 
develop  themselves  around  and  between  them. 

This  intermediate  development,  owing  to  the  imperfection  of 
the  lower  connective  tissue,  becomes  a  band  or  rim  where  the  two 
conically  formed  bladders  push  together,  so  that  they  can  not  become 
a  symmetrical  whole,  but  have  an  intermediate  arch.  In  these  cases 
the  cause  probably  lies  in  the  patency  of  the  urachus  and  the  eversion 
of  the  bladder ;  also  the  open  condition  of  the  abdominal  walls,  inter- 
ference with  the  development  of  the  lower  parts  of  the  musculi  recti, 
and,  later,  the  imperfect  development  of  the  pelvis. 

There  can,  however,  be  a  fissure  of  the  abdominal  walls  without 
a  fissure  of  the  bladder,  the  closed  organ  protruding  from  the  ab- 
dominal fissure  (ectopia  vesicae). 

Lately  Ahlfeld  has  brought  forward  the  hypothesis  that  eversion 
of  the  bladder  is  complicated  with  and  dependent  on  a  pulling  down- 
ward of  the  ductus  omphalo-meseraicus,  making  an  obtuse  angle  in- 
feriorly,  whereby,  the  rectum  being  pushed  forward,  it  pushes  the 
inferior  wall  of  the  allantois  before  it.  Communication  between  the 
rectum  and  the  allantois  ceases,  and  the  allantois,  becoming  enor- 
mously distended,  bursts.     Ruge  and  Fleischer  contend  that  in  this 


682  DISEASES   OF   WOMEN. 

affection  the  duct  of  the  iimbihcal  vesicle  is  implicated,  and  hold 
that  the  tense  cord  (duct)  in  question  is  a  continuation  of  the  uraehus. 

Winckel  is  of  the  opinion  that  bursting  of  the  bladder  at  an 
early  stage  from  urine-pressure  is  the  weightiest  cause  in  the  produc- 
tion of  bladder  fissure.  Against  the  idea  of  Rose,  which  is  that 
eversio  vesicae  does  not  take  place  from  rupture,  Winckel  says  that 
the  jjresence  of  scars  is  not  absolutely  necessary  to  prove  the  point, 
for  the  abdominal  walls  are  not  yet  joined,  and  therefore  can  not  be 
ruptured ;  and,  moreover,  he  has  often  seen  children  immediately 
after  birth  in  whom  the  umbilical  cord  was  normal,  and  yet  an  ever- 
sion  of  the  bladder  existed.  He  raises  the  query  as  to  why  we  can 
not  have  rupture  of  the  bladder  at  an  early  period,  since  we  know 
that  it  occurs  later  in  Hfe,  as  in  w^omen  with  retroflexion  of  the 
gravid  uterus. 

Another  fact  that  he  advances  in  favor  of  the  view  that  rupture 
of  the  bladder  is  due  to  urethral  obstruction  is  that  it  occurs  oftener 
in  males  than  in  females,  the  former  having  a  canal  much  more  favor- 
able to  such  obstruction,  for,  of  sixteen  cases  of  vesico-umbilical  fist- 
ula, given  by  Stadtfeldt,  fourteen  were  males  and  two  females.  Dr. 
AVunder,  of  Altenberg,  in  1831  observed  the  cases  of  two  boys,  aged 
respectively  eight  and  eleven,  with  congenital  eversion  of  the  blad- 
der.    It  is  interesting  to  note  that  their  mothers  were  sisters. 

The  various  causes  that  give  rise  to  vesical  fissure  produce  also 
imperfectly  developed  pelvic  bones,  dislocation  of  the  head  of  the 
femur,  and  other  malformations  from  pressure.  The  excessive  dilata- 
tion of  the  bladder  drives  the  horizontal  rami  of  the  pubes  asunder, 
and  the  changed  direction  and  imperfect  growth  of  the  pelvic  bones 
cause  a  lessened  acetabular  circumference  and  consequent  slipping 
out  of  the  head  of  the  femur.  Thus  does  Voss  explain  the  disloca- 
tion occurring  in  one  of  his  cases. 

It  will  be  found  on  touching  the  red  mucous  membrane  of  an 
exposed  bladder  that  it  is  exceedingly  sensitive.  In  such  a  case  the 
urine  may  be  seen  oozing  from  the  ureters  and  diibbling  over  the 
surface.  The  mucous  membi-ane  is  often  protruded  and  wi-inkled 
up  by  the  movements  of  the  bowels,  and  can,  in  case  the  bladder- 
opening  is  great,  be  inverted  through  the  fissure  (inversio  vesicas  per 
fissuram)  or  through  the  uraehus  (inversio  vesicae  per  urachum).  If 
the  fissure  is  small  it  may  remain  for  years  without  any  inversion. 
If  the  prolapsed  mucous  membrane  is  replaced  and  indirect  pressure 
is  made  on  the  dilated  ureters,  the  urine  will  spurt  from  the  ureteric 
orifices. 

Sometimes  these  patients  have  partial  control  over  their  urine : 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   683 

as  in  cases  where  an  umbilical  hernia  exists  with  umbilical  fissure, 
the  posterior  wall  of  the  bladder  being  forced  into  the  opening 
plugs  it  up.  Such  a  case  is  described  by  Paget.  The  hernial  sac, 
which  was  about  the  size  of  a  goose-egg,  completely  plugged  the 
umbilical  foramen  by  pressing  firmly  against  the  posterior  bladder- 
wall.  If  the  patient  desired  to  urinate,  the  contraction  of  the  blad- 
der caused  a  gradual  disappearance  of  the  hernial  tumor ;  and  when 
it  had  entirely  disappeared  he  passed  urine  from  the  umbilicus  and 
then  through  the  urethra.  After  the  urethral  flow  began  the  stream 
from  the  umbilicus  ceased,  and  no  urine  passed  at  that  point  unless 
strong  pressure  was  made  upon  the  abdomen. 

Another  way  in  which  partial  retention  may  be  accomplished  in 
imperfect  eversion  is  by  the  greatly  thickened  muscular  walls  acting 
as  a  sort  of  sphincter.  Such  a  case  given  by  Yoss  is  that  of  a  female 
child,  twenty  months  old.  When  lying  down  and  quiet,  the  urine 
did  not  flow  away  so  freely.  The  bladder-wall  was  nearly  one  inch 
in  thickness,  and  the  ureters,  though  three  inches  broad,  were  greatly 
narrowed  at  their  point  of  entrance  into  the  bladder. 

In  fissures  situated  low  down  there  may  be  coincident  inguinal 
hernia,  as  is  illustrated  by  a  case  related  by  Bertet.  This  comphca- 
tion  may  act  so  as  to  aid  in  the  retention  of  urine.  From  the  con- 
stant flow  of  urine,  the  inferior  end  of  the  fissure  and  neighboring 
parts  become  moist,  red,  eroded,  and  sometimes  incrusted  and  ulcer- 
ated. There  are  various  painful  sensations,  as  itching  and  burning, 
and  the  patient  becomes  a  nuisance  to  herself  and  to  those  about  her 
from  the  offensive  urinous  odor  that  is  constantly  given  off. 

The  edges  of  the  mucous  membrane  in  time  become  changed, 
and  resemble  skin  in  appearance.  At  other  points,  oftentimes,  the 
membrane  is  much  changed,  having  upon  its  surface  loose,  villous 
growths,  that  bleed  readily  when  touched,  and  give  the  impression 
of  a  malignant  new-formation. 

By  reason  of  a  separation  of  the  pelvic  bones  there  is  an  irregu- 
lar, uncertain  gait.  The  pelvic  diametric  proportions,  as  observed 
by  Moergelin,  are  in  these  cases  much  changed,  the  transverse  being 
much  greater  than  the  antero-posterior,  the  dissimilarity  increasing 
as  age  advances,  the  proportion  being  sometimes  trebled.  Women 
with  these  troubles,  however,  have  borne  children. 

A  close  inspection  of  the  ureteric  openings  being  possible  in 
these  cases,  the  interesting  observation  may  be  made  that  in  action 
the  kidneys  seem  quite  independent,  the  one  of  the  other,  the  right 
discharging  urine  and  the  left  none,  or  the  reverse,  or  both  may  dis- 
charge together. 


684  DISEASES   OF  WOMEN". 

Diagnosis. — the  diagnosis  of  urachal  fistula  is  comparatively 
easy,  for  the  affection  is  at  once  recognized  by  finding  the  ureteric 
orifices  with  the  mine  flowing  from  them. 

As  to  frequency,  the  following  statistics  are  of  importance  : 

In  12,689  new-bora  children,  Sickles  found  this  malformation  to 
occur  twice  in  twenty-seven  cases  of  developmental  anomalies. 

In  thirty-five  hundred  births  occurring  in  the  Dresden  Institute, 
from  1872  to  1875,  Winckel  saw  one  case, 

Velpeau,  in  the  year  1833,  mentions  seeing  and  finding  on  record 
more  than  one  hundred  cases  of  this  kind.  Percy  says  that  he  has 
seen  it  twenty  times  in  his  own  practice.  Winckel  saw  five  cases, 
three  of  which  were  girls,  and  two  boys.  Phillips  saw  twenty-one 
cases,  all  girls ;  but  in  Wood's  twenty  cases,  only  two  were  girls. 

Prognosis. — The  prognosis  is  usually  unfavorable.  The  children 
are  weak  and  puny,  and,  as  a  rule,  die  early.  They  are,  however, 
seldom  destroyed  by  the  fissure  itself.  Many  of  them  are  born  liv- 
ing, and  can  be  kept  alive,  and  some  attain  a  fair  age.  Lebert  saw 
in  Salpetriere  Hospital,  Paris,  an  old  woman  with  this  affection. 
Operative  procedures  and  the  various  apparatus  to  prevent  trick- 
ling of  urine  are  of  little  avail.  This,  however,  is  only  the  case 
in  total  eversion.  Urachal  fistulae,  simple  tistulse,  above  the  pubic 
symphysis,  and  even  those  situated  inferiorly,  where  the  pubic 
bones  are  united,  may  be  readily  cm-ed  by  the  ordinary  operation  for 
fistula. 

Treatment. — Stadtfeldt  operated  in  eight  cases  of  urachal  fistula, 
in  seven  of  which  he  obtained  perfect  healing.  In  deep  fistula  he 
recommends  freshening  of  the  edges  of  the  skin  and  mucons  mem- 
brane, and  attempting  union  by  the  first  intention.  In  cases  where 
the  edges  extrude  themselves  yhyj  much,  he  puts  on  either  a  clamp 
or  ligature. 

Winckel  favors  operative  procedure  since,  in  that  way,  the  ab- 
normal protiiision  can  be  removed.  Sometimes,  as  recommended  by 
Paget,  it  will  be  sufficient  to  freshen  the  edges,  put  in  insect-pins, 
ligature,  and  union  may  be  expected  in  from  two  to  four  weeks. 

In  fissura  vesicae,  superior  or  inferior,  an  attempt  might  be  made 
to  draw  the  edges  together,  and  even  to  loosen  the  skin  in  front  by 
incision,  so  as  to  remove  traction  from  the  edges.  In  that  case  it 
will  be  necessary  to  freshen  the  edges  and  put  in  sutures.  The  re- 
sult, unfortimately,  is  not  uniformly  successful. 

In  earlier  times,  in  cases  of  true  eversion  of  the  bladder,  no  one 
dared  to  operate,  and  the  only  alleviation  granted  to  the  patient 
was  such  as  could  be  obtained  by  a  properly-adapted  urinal.     Ku- 


MALFORMATIONS   OF   THE   BLADDER   AND   URETHRA.      685 

meroiis  appliances  have  been  invented  for  tins  purpose,  some  of 
them  very  useful. 

Gerdy  was  the  first  to  operate  for  eversion  by  closure.  Failing 
to  bring  an  inverted  bladder  back  into  place,  he  tried  to  form  a  suf- 
ficient sac  by  partial  excision  of  the  ureters.  The  patient,  a  man, 
was  attacked  with  peritonitis  and  nephritis,  and  died. 

Jules  Koux,  in  1853,  proposed  cutting  out  the  ureters,  and  unit- 
ing them  with  the  rectum.  Simon  tried  this  once,  and  succeeded ; 
but  the  patient  died  six  months  after  from  peritonitis  and  exhaus- 
tion. At  a  later  date,  he  again  attempted  to  treat  this  malforma- 
tion by  operative  procedures.  He  made  one  inferior  and  two  lateral 
flaps,  but  these  became  gangrenous.  Ten  years  later,  these  attempts 
were  more  successfully  made  by  John  Wood  and  Holmes,  and  their 
results  recorded  by  Podruzski. 

The  first  one,  however,  who  obtained  a  perfect  result  was  Dr. 
Daniel  Ayres,  of  Brooklyn.  He  cut  a  long  flap  from  the  under  and 
lower  side  of  the  abdominal  walls,  turned  the  skin-side  in,  and 
united  it  with  both  edges  of  the  bladder.  A  full  account  of  this 
case  will  be  found  at  the  close  of  this  chapter.  Since  then  I  have 
seen  three  cases,  but  as  they  were  not  patients  of  mine  I  had  no 
opportunity  to  interfere  surgically  in  their  treatment. 

Subsequently,  Wood  operated  on  a  girl  one  year  and  a  half  old, 
whose  bladder-fissure  was  continuous  with  the  uro-genital  sinus,  so 
that  the  os  and  cervix  uteri  were  always  wet.  He  raised  one  flaj) 
from  the  neighborhood  of  the  umbilicus,  and  another  from  the 
soft  parts,  and  turning  the  skin-side  in,  covered  them  with  a  larger 
flap  from  the  other  side.  The  mucous  membrane,  however,  pushed 
through  inferiorly,  and  broke  the  fresh  adhesions. 

Ashhurst's  case  was  more  successful.  He  cut  a  piece  from 
under  the  umbilicus,  and  joined  it  with  two  flaps  from  the  sides 
(they  being  somewhat  turned)  so  that  their  upper  edges  met  each 
other  in  the  median  line.  They  were  joined  by  sutures,  and  through 
each  side  of  the  upper  flaps  two  pieces  of  malleable  iron-wire  were 
carried,  then  drawn  through  the  lateral  flaps,  and  twisted  over  little 
rolls  of  plaster.  Traction  was  thus  relieved.  The  flaps  healed  by 
the  first  intention.  The  sutures  were  removed  on  the  eighth  day. 
The  rest  of  the  wound  healed  by  granulation.  When  in  the  up- 
right position,  incontinence  of  urine  still  continued  ;  but  when  lying 
upon  her  back,  the  patient  was  able  to  retain  urine  for  about  two 
hours,  her  general  condition  being  thus  greatly  improved. 

Ashhurst  gives  a  resxLine  of  twenty  cases  of  eversio  vesicae,  oper- 
ated on  up  to  his  time.     Fourteen  of  these  were  successful — Ayres, 


686  DISEASES   OF   WOMEN. 

Holmes,  Wood,  Morey,  and  Barker,  each  being  credited  with  one, 
Three  were  unsuccessful,  by  Holmes  and  Wood ;  and  three  resulted 
fatally,  by  Richard,  Pancoast,  and  Wood.  In  the  last  two  death 
resulted  from  causes  other  than  the  operation. 

In  all  cases  when  the  skin  is  turned  in,  the  growth  of  hair  al- 
ready present  or  to  come  will  ])e  apt  to  give  rise  to  incrustations. 
Thiersch,  in  his  six  cases,  allowed  the  flaps  to  granulate  on  their  raw 
surface  before  applying  them.  When  the  flap-union  is  perfect,  he 
advises  closing  completely  the  upper  part  of  the  bladder. 

The  diagnosis  of  double  bladder  may  be  made  by  urethral  dilata- 
tion and  exploration  by  the  finger  and  catheter. 

Destruction  of  the  bladder-septa  is  not  to  be  thought  of.  In  case 
of  the  existence  of  urachal  cyst  causing  difficult  urination,  one  might 
try  extirpation  of  the  cyst  by  cutting  into  the  abdominal  \xa\\s,  and 
after  freshening  their  edges  unite  them  with  those  of  the  bladder. 

ILLUSTRATIVE    CASES. 

Extroversion  of  the  Urinary  Bladder.  (By  Daniel  Ay  res,  M.  D., 
LL.  D.) — The  patient  was  admitted  to  the  Long  Island  College  Hos- 
pital, November  1,  1858,  and  a  history  of  the  case  recorded  by  the 
house  surgeon,  Dr.  Ostrander. 

She  is  twenty-eight  years  of  age,  born  of  healthy  parents,  both 
of  whom  were  free  from  deformity ;  her  height  is  below  the  aver- 
age of  females,  and  she  is  unmarried.  She  declares  her  health  to 
have  been  always  good,  appetite  and  digestion  excellent,  bowels 
regular,  and  the  catamenia  in  all  respects  normal. 

She  states  that,  on  the  5th  of  July  preceding,  she  was  delivered 
of  a  well-developed  child,  having  carried  it  to  maturity  without 
extraordinary  difficulty.  Labor  commenced  with  free  hfiemorrhage 
(footling  presentation),  and  lasted  two  hours,  at  the  end  of  which 
time  the  child  was  bom,  having  died  in  process  of  delivery.  Peri- 
naeum  uninjured.  She  reports  having  made  a  tolerable  recovery, 
though  for  a  long  time  weak,  and  her  present  appearance  is  some- 
what anaemic. 

Shortly  after  she  began  walking  about  symptoms  of  prolapsus 
uteri  came  on,  becoming  gradually  worse,  until  the  organ  projected 
external  to  the  vulva,  attended  with  dorsal,  dragging  pain,  difficulty 
of  locomotion,  and  gastric  disturbance. 

In  quest  of  relief,  she  entered  the  Brooklyn  Cit}'  Hospital  on 
the  Ist  of  September  following  her  confinement,  and  remained  there 
one  month.  Here  she  states  that  a  variety  of  jiessaries  were  tried, 
none  of  which  could  be  retained,  and  finally  a  surgical  operation 


MALFORMATIONS   OF   THE   BLADDER   AND   URETHRA.      687 

was  performed,  tlie  nature  and  character  of  which  is  not  very  appar- 
ent. A  short  article,  descriptive  of  this  ease,  appeared  in  the  "Vir- 
ginia Medical  Journal"  for  January,  1859,  written  by  the  house 
surgeon  of  that  institution.  Tlie  writer  states  that  an  attempt  was 
made  to  retain  the  prolapsed  uterus  "  by  removing  an  inch  of  mu- 
cous membrane  from  the  bottom  and  sides  of  the  vulva,  and  unit- 
ing them  by  two  ligure-of-eight  sutures,  which  were  removed  on 
the  sixth  day,  when  no  adhesion  was  found  to  have  taken  place." 
The  writer  continues :  "  The  patient  was  allowed  to  get  up  on  the 
fourteenth  day,  when  the  prolapsus  was  found  to  exist  nearly  as 
much  as  before,"  etc. 

It  is  obvious  that  no  effort  was  made  to  relieve  the  congenital 
deformity,  and  that  she  was  discharged  in  much  the  same  condition 
as  when  she  entered. 

Finally,  a  species  of  stem-pessary  was  contrived  which  was  in- 
tended to  support  the  uterus,  while  kept  in  position  by  strings 
passed  around  the  thighs.  This,  however,  proved  very  inefficient — 
the  uterus  slipping  by  the  instrument  upon  the  slightest  extra  exer- 
tion. Moreover,  the  parts  had  now  assumed  an  irritable  condition, 
partly  due  to  increased  friction  of  the  apparatus,  and  undue  attention 
to  cleanliness,  added  to  the  causes  already  noted  ;  altogether,  her  de- 
plorable condition  was  scarcely  susceptible  of  being  made  worse. 

I  may  here  remark  that  the  figures,  both  before  and  after  the 
operation,  have  been  photographed  from  accurate  plaster- casts,  taken 
directly  from  the  patient — a  very  difficult  and  delicate  procedure, 
for  which  I  am  much  indebted  to  the  skill  and  kindness  of  my 
colleague  Dr.  Bauer,  and  our  valuable  assistant,  Mr.  J.  F.  Esslinger. 

Fig.  246  is  an  exact  representation  of  the  parts  at  the  time  of 
presentation  to  the  clinical  class  of  the  Long  Island  College  Hospi- 
tal, for  the  purpose  of  critical  examination.  The  prolapsus,  having 
been  carefully  and  completely  reduced,  was  found  to  retain  its  place 
so  long  as  the  patient  maintained  the  recumbent  position. 

The  distance  between  pubic  abutments  was  estimated  at  about 
three  inches. 

The  bladder  {a)  formed  an  oval,  elliptical  tumor,  mammillated 
upon  the  surface,  which  in  the  recumbent  position  measured  two 
inches  in  its  long,  and  one  inch  and  a  quarter  in  its  short  diame- 
ter. This  was  soft,  elastic,  or  bright  verniihon  color,  and  covered 
with  a  thick  tenacious  mucus ;  bleeding  readily  when  rudely  han- 
dled, and  so  exquisitely  sensitive,  that  while  under  the  full  influence 
of  chloroform,  and  insensible  to  the  knife,  a  sponge  passed  over  the 
exposed  bladder  excited  reflex  motions. 


688 


DISEASES  OF  WOMEN. 


The  integument  immediately  surrounding  the  bladder  was  found 
red  and  puckered,  but  very  soft,  delicate,  and  free  from  hair  be- 
tween the  bladder  and  point  of  sternum.     The  labia  majora  (o,  <?,) 

thick,  fleshy,  and  luxuri- 
— -^  X.  ]  I  antly  covered  with  hair, 

were  gathered  into  folds 
swelling  away  toward 
either  thigh  ;  these  were 
carefully  shaved  previous 
to  taking  the  cast  and  per- 
forming the  operation. 

The  nymphse  occu- 
pied isolated  positions 
on  each  side  of  the  vul- 
va, and  are  designated  in 
all  the  figures  by  the  let- 
ters b,  h. 

Between  these  and 
the  vagina  below  no  trace 
of  clitoris  or  urethra  could 
be  distinguished,  but  the 
whole  surface  was  cov- 
ered with  mucous  mem- 
brane, continuous  with 
the  vaginal  lining. 

Here,  then,  we  had 
to  contend  with  two  formidable  difficulties,  either  of  which  was  a 
problem  in  itself,  viz.,  aggravated  prolapsus  from  an  entire  ab- 
sence of  an  anterior  support,  added  to  the  original  congenital  mal- 
formation. 

To  form  an  estimate  of  the  value  attached  to  surgical  operations 
in  these  cases,  we  can  not  do  better  than  quote  the  opinion  of  Prof. 
Erichsen,  of  University  College,  London.  Having  collected  the 
experience  of  the  profession  on  this  topic,  liis  eminent  position  at 
the  center  of  surgical  science,  added  to  his  well-known  and  exten- 
sively recognized  erudition,  renders  him  at  once  a  reliable  and  com- 
pendious authority  on  the  subject. 

"  This  malformation,"  says  he,  "  is  incurable.  Operations  have 
been  planned,  and  performed  with  a  view  of  closing  in  the  exposed 
bladder  by  plastic  procedures,  but  they  have  never  proved  success- 
ful, and  have  terminated  in  some  instances  in  the  patient's  death ; 
they  do  not,  therefore,  afford  nmch  encouragement  for  repetition." 


■-- / 

Fig.  246. — Extroversion  of  the  bladder,  c,  Bladder 
exposed,  forming  a  bright  vermilion  tumor ;  6,  6, 
labia  minora ;  o,  o,  above  labia  majora ;  c,  vagina ; 
d^  anus. 


MALFORMATIONS   OF   THE   BLADDER   AND   URETHRA.      689 


So  unsatisfactory  have  been  the  results  of  these  operations  that 
the  proiession  has  not  been  favored  with  their  general  plan,  their 
details,  nor  the  causes  of 
failure.  It  must  be  evi- 
dent, however,  that  op- 
erations based  upon  the 
principles  of  plastic  sur- 
gery alone  offer  pros- 
pects of  success. 

The  most  probable 
source  of  failure,  and 
one  which  challenged 
our  early  attention,  was 
the  disastrous  result  to 
be  apprehended  from 
urinary  infiltration, 

which,  by  its  irritating 
character,  would  neces- 
sarily destroy  all  pros- 
pect of  union,  if  it  did 
not  induce  extensive 
sloughing  of  the  abdom- 
inal parietes ;  peritonitis 
and    punilent    phlebitis 

are  likewise  probable  sources  of  danger,  unless  carefully  guarded 
against.  Indeed,  these  may  all  become  inevitable  consequences  of 
attempting  to  accomphsh  too  much  at  one  time ;  and  it  was  there- 
fore determined  to  arrange  our  proceedings  with  a  special  view,  if 
possible,  to  avoid  them.  The  indications  which  it  was  proposed  to 
follow  were : 

1.  To  form  an  anterior  wall  for  the  exposed  bladder. 

2.  To  restore  the  urinary  canal. 

3.  To  establish  the  anterior  fourchette  of  the  vulva. 

4.  To  supply  means  to  prevent  the  prolapsus,  and  to  collect  the 
renal  secretions. 

The  delicate  character  of  the  integument  above  the  bladder  and 
its  well-known  transmutability  into  the  conditions  of  a  mucous  mem- 
brane peculiarly  adapted  it  to  supply  the  anterior  cystic  wall,  and 
thus  fulfill  the  primary  indication. 

With  these  objects  in  view,  the  oj)erative  proceedings  were  di- 
vided into  two  stages. 

The  first  consisted  in  raising  a  flap  from  the  anterior  portion  of 
45 


Fig.  24 '7. — e,  Linear  cicatrix,  fonned  by  the  flaps  cov- 
ering the  bladder ;  b,  b,  nymphae  brought  together, 
and  inclosed  by  the  vulva. 


690 


DISEASES   OF   WOMEN. 


the  abdomen,  including  the  superficial  fascia,  turning  its  cuticular 
surface  down  over  the  exposed  bladder  as  far  as  its  inferior  border, 
and  securing  the  lateral  union  of  the  flap  in  that  position,  while  a 
free  exit  below  was  maintained  for  the  urinary  discharge ;  an  im- 
portant result,  still  further  assisted  by  the  dependent  situation  of 
the  outlet  of  the  ureters  already  alluded  to. 

By  these  means  it  was  proposed  to  accustom  the  highly  sensitive 
bladder  to  a  gradual  and  methodical  compression  while  the  flap  it- 
self was  insured  ample  space  to  undergo  such  swelling  as  might  be 
anticipated  from  its  new  position  and  the  unusual  stimulation  of  a 
new  secretion.  Time  was  likewise  given  for  the  necessary  trans- 
mutation of  tissues  to  make  some  progress. 

The  steps  of  this  procedure  will  perhaps  be  better  understood 

by  a  more  detailed  state- 
ment of  the  first  operation, 
in  connection  with  the  di- 
agrammatic plates,  Figs. 
2-1:8  and  249. 

It  was  performed  on 
the  16th  of  November  last, 
the  patient  being  thor- 
oughly under  the  influ- 
ence of  chloroform,  and  a 
sugar  -  loaf  -  shaped  flap 
having  been  previously 
marked  out  upon  the  ab- 
dominal integument  ;  its 
base,  E,  F,  three  inches  in 
width,  was  situated  three 
fourths  of  an  inch  above 
the  cystic  tumor,  and  ex- 
tended five  inches  in 
length,  with  its  apex  to- 
ward the  ensifornj  cai-ti- 
lage.  The  dark  line  E,  H,  G,  I,  F  (Fig.  248),  indicates  its  form, 
position,  and  the  line  of  incision. 

This  flap  being  left  suflftciently  large  to  meet  the  elevated  form 
of  the  bladder  and  allow  for  shrinkage,  was  quickly  but  carefully 
separated  from  its  cellular  attachments,  down  to  the  line  E,  F, 
while  two  lateral  incisions,  E,  J,  and  F,  K,  were  continued  directly 
downward  and  toward  the  nymphae,  to  serve  as  beds  for  receiving 
the  sides  of  the  new  flap. 


Fig.  248. — a,  Bladder,  covered  by  deep  flaps ;  b,  b, 
nymphie  ;  c,  vagina  ;  D,  anus. 


MALFORMATIONS  OF   THE  BLADDER   AND   URETHRA.      691 


The  integuments  covering  the  lateral  and  inferior  portions  of  the 
abdomen,  extending  from  G  to  J  on  one  side,  and  from  G  to  K  on 
the  other,  were  now  sufficiently  separated  from  their  cellular  attach- 
ments to  the  muscles  beneath  to  insure  their  sliding  freely,  and  meet- 
ing without  tension  at  the  mesial  line,  G,  K  (Fig.  248).  When 
brought  into  this  position  they  completely  covered  from  view  the 
raw  surface  of  the  flap  already  turned  over,  and  investing  the  blad- 
der, with  the  exception 
of  a  triangular  space, 
J,  N,K  (Fig.  248),  formed 
by  the  coaptation  of  the 
lateral  flaps  ;  this  was 
temporarily  covered  by 
reflecting  back  upon  it- 
self the  corresponding  tri- 
angular free  end  of  the 
deep  flap,  J,  C,  K  (Fig. 
248),  and  attaching  it 
along  the  line,  J,  I^,  K. 
jSTumerous  points  of  in- 
terrupted suture  were 
used  to  retain  the  parts 
in  situ,  assisted  by  long 
strips  of  adhesive  plaster, 
compresses,  and  a  reten- 
tive bandage  around  the 
body.  It  will  be  observed 
that  the  lower  portion  of 

the  cystic  tumor  was  thus  temporarily  left  free  and  partially  ex- 
posed, while  no  portion  of  cut  or  denuded  surface  remained  uncov- 
ered. 

The  patient  received  a  large  dose  of  opium,  and  was  strictly 
maintained  in  the  recumbent  position  upon  a  bed,  properly  pro- 
tected; such  additional  measures  being  adopted  as  would  secure 
cleanliness. 

As  the  parts  subjected  to  operation  began  to  swell,  she  com- 
plained of  irritation  and  pressure  upon  the  bladder,  which,  however, 
were  promptly  met  with  morphine  alone,  and  subsided  in  the  course 
of  a  few  days.  Now  was  exhibited  the  great  importance  of  leaving 
the  tumor  partially  uncovered,  while  all  the  cut  surfaces  were  in 
close  contact,  and  thus  freed  from  the  action  of  irritating  secretions ; 
important  facts  duly  dwelt  upon  and  recently  enforced  with  great 


249. — A,  Bladder  ;  b,  b, 
anus. 


nymphse  ;  c,  vagina  ; 


692  DISEASES   OF  WOMEN. 

stress  by  the  distinguished  Prof.  Syme,  of  Edinburgh,  whose  con- 
tributions to  the  surgical  treatment  of  the  urinary  organs  have  alone 
placed  both  hemispheres  under  permanent  obligation  to  him. 

On  the  fourth  day  after  the  operation  all  sutures  were  removed, 
the  wounds  having  healed  by  first  intention  or  primary  adhesion, 
with  the  exception  of  a  spot  the  size  of  a  ten-cent  piece,  situated 
just  above  the  point  of  the  triangle,  and  where  the  deep  fiap  had 
been  reflected  over  the  bladder.  At  this  point  the  lateral  abdominal 
flaps  were  necessarily  raised  up  from  the  tissues  beneath,  and  could 
not  be  brought  into  contact  even  by  the  use  of  compresses.  This, 
however,  granulated  kindly,  and  was  nearly  cicatrized  on  the  7th  of 
December,  when  the  second  and  last  operation  was  performed,  as 
follows : 

The  patient  being  under  the  influence  of  chloroform  the  lower 
triangular  flap,  J,  N,  K  (Fig.  248),  was  dissected  from  its  recent  and 
temporary  attachments,  both  lateral  and  deep,  and  tm'ned  down  over 
the  vulva  as  indicated  by  the  dotted  line,  J,  C,  K. 

Two  incisions,  J,  L,  and  K,  M,  were  now  carried  from  the  ex- 
ternal angles  of  this  triangle,  perpendicularly  toward  and  terminat- 
ing just  behind  the  nympiise,  B,  B. 

The  lateral  flaps  bounded  by  the  lines  N,  J,  L,  and  N,  K,  M, 
and  including  the  labia  majora,  were  then  freely  dissected  from  over 
the  abutments  of  the  pubic  bones  until  they  could  be  readily  slid  to 
meet  each  other  at  the  central  line,  N,  C,  which,  being  a  continua- 
tion of  the  line  G,  N,  reduced  the  whole  to  a  single  linear  wound, 
occupying  the  "  linea  alba."     (See  Fig.  247.) 

During  the  operation  several  arterial  branches  bled  freely,  and 
were  arrested  by  torsion  and  the  free  application  of  ice,  after 
which  the  flaps  were  confined  at  the  mesial  line  by  points  of  inter- 
rupted suture,  the  most  inferior  one,  viz.,  at  L,  and  M,  being  made 
to  include  the  apex  C,  of  the  triangular  flap. 

Fearing  to  depend  on  sutures  alone  to  secure  the  approximated 
flaps,  and  the  use  of  adhesive  plaster  being  excluded  by  the  irregu- 
larity and  position  of  the  parts,  the  whole  surface  between  the  points 
of  suture  was  hermetically  incased  by  strips  of  patent  lint,  soaked 
in  collodion  and  accurately  applied.  In  addition  to  this,  pieces  of 
nmslin  were  by  the  same  method  flrmly  attached  to  the  labia  majora, 
at  some  distance  from  tlie  mesial  line,  and  to  these  sutures  silk  was 
fastened  in  such  manner  as  to  form  a  lacing  across  and  over  the 
wound.  By  means  of  this  dressing  all  tension  was  removed  from 
the  sutures,  urine  was  totally  excluded,  while  rapid  and  perfect  ad- 
hesion soon  followed. 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   693 

Thus  a  uriuary  canal  was  formed  which  would  admit  the  little 
fino-er  to  be  passed  up  one  inch  and  a  half.  The  anterior  four- 
chette  of  the  vulva  was  firmly  established,  and  the  mons  veneris 
assumed  its  prominent  and  natural  appearance. 

The  last  cast  of  the  parts  representing  her  present  condition 
(Fig.  2i7)  was  taken  on  the  4th  of  January,  1859,  previous  to  which 
time,  the  parts  being  all  firmly  united,  she  was  permitted  freely  to 
walk  about,  and  left  the  hospital  to  spend  the  holidays  with  her 
friends.  No  artificial  support  whatever  was  applied,  in  order  to  as- 
certain how  far  the  operation  would  succeed  in  preventing  the  pro- 
lapsus. 

After  a  severe  test,  the  anterior  fold  of  the  vagina  alone  de- 
scended, and  that  for  a  short  distance,  forming  a  pale,  oedematous 
tumor,  occupying  the  vulva,  about  the  size  of  an  English  walnut. 
The  anterior  fourchette  of  the  vulva  remaining  firm  and  resisting,  a 
light,  oval  pessary,  made  of  vulcanized  ruhber,  and  perforated,  was 
introduced  into  the  vagina  and  readily  retained  in  situ.  After  thor- 
ough trial,  this  was  found  to  support  the  parts  completely,  and  with- 
out the  slightest  uneasiness,  even  under  active  exertion  and  straining. 

This  was  a  better  result  than  had  been  anticipated,  inasmuch  as 
it  was  intended  to  rely  mainly  upon  a  disk-shaped  pessary,  sup- 
ported by  a  foot  attached  to  a  simple  apparatus  which  we  had  con- 
structed to  act  as  a  reservoir  for  the  urine. 

January  20,  1859.  The  patient  was  again  examined  at  the  hos- 
pital, in  the  presence  of  a  number  of  medical  gentlemen,  she  having 
walked  a  distance  of  two  miles  without  experiencing  any  incon- 
venience. The  parts  were  all  found  sound  and  firm,  and  her  gen- 
eral health  and  spirits  much  improved. 

Patent  TJraclius  with  Calculus.  (H.  D.  Yosburgh,  M.  D.,  "New 
York  Medical  Record,"  September  22,  1877.) — Several  months  ago 
I  was  called  to  see  J.  H.  B.,  fifty,  a  mechanic,  of  spare  habit,  and 
always  in  good  health.  He  complained  of  soreness  and  constant 
pain  at  the  umbilicus,  and  on  examination  I  found  the  natural  de- 
pression filled  up  by  a  rounded  tumor,  apparently  the  natural  tissue 
enlarged  by  swelling.  There  was  also  circumscribed  hardness  of  the 
tissues  around  the  umbihcus.  The  parts  were  red  and  very  tender 
to  the  touch,  having  every  appearance  of  an  ordinary  erysipelas. 

At  the  time  of  my  visit  he  told  me  that  a  score  or  more  of  years 
before,  after  a  similar  experience,  his  attending  physician  at  that 
time  removed  a  "  stone  "  from  the  umbilicus.  I  applied  a  poultice, 
and  awaited  developments.  The  above  condition  continued  from 
day  to  day,  with  the  exception  that  the  tumor  projected  more  and 


694  DISEASES   OF  WOMEN. 

more  from  the  umbilicus,  and  the  circumscribed  hardness  decreased. 
Anj  movement  of  the  body  or  handling  of  the  tumor  produced  se- 
vere cutting  pain  in  the  part,  The  tumor  was  exquisitely  tender. 
No  constitutional  symptoms  accompanied  the  trouble. 

On  the  tenth  day  from  my  first  visit  I  made  an  incision  into  the 
tumor  for  the  j)urpose  of  exploration,  about  half  an  inch  in  depth, 
when  I  came  upon  a  hard  substance  which,  after  considerable  diffi- 
culty, I  removed,  and  found  to  be  a  concretion,  smooth  and  ovoid 
in  shape,  about  the  size  of  a  medium  hickory-nut,  and  of  the  color 
and  appearance  of  a  phosphatic  calculus,  with  a  strong  urinous 
smell.  After  the  removal  the  wound  readily  healed.  The  ordinary 
retraction  of  the  tissues  within  the  navel  fossa  took  place,  and  the 
man  has  suffered  no  inconvenience  since. 

What  was  the  concretion  ?  In  the  "  Medical  Record,"  No.  354, 
Dr.  Rose's  article  describing  a  patent  urachus  called  this  case  to 
mind,  and  I  have  transcribed  the  above  from  my  notes  of  the  time. 

I  can  not  conceive  this  concretion  to  have  been  anything  else 
than  a  calculus  formed  from  urinary  deposit  in  a  patent  urachus. 

No  treatise  within  my  reach  mentions  anything  of  the  kind,  and 
the  novelty  of  the  case  is  my  reason  for  rejjorting  it. 

In  this  man  there  was  doubtless  a  similar  calculus  formation 
something  more  than  twenty  years  before. 

Very  Rare  Form  of  Monstrosity  of  the  Female  Genito-Urinary  Or- 
gans {-'  Gazette  des  HoiDitaux.") — In  the  words  of  M.  Tillaux,  at  the 
Hospital  Lariboisiere,  there  is  at  present  a  small,  deformed  woman, 
twenty-six  years  of  age,  who  presents  an  exstrophy  of  the  bladder, 
with  complete  absence  of  the  vagina.  The  external  organs  of  gen- 
eration are  represented  only  by  the  orifice  of  the  uterus,  which  is 
situated  in  the  median  line  almost  on  a  level  wdth  the  skin,  and  by 
rudimentary  labia  minora  and  majora  which  are  not  united  in  front. 
The  clitoris,  urethra,  and  anterior  wall  of  the  bladder  are  absent. 
The  ureters  open  into  the  rudimentary  bladder  near  the  median  line. 
Palpation  shows  that  the  pubic  bones  are  separated  in  front  by  a 
space  that  is  about  as  wide  as  five  fingers,  and  the  pelvis  seems  to 
be  enlarged  to  that  extent.  The  umbilical  cicatrix  is  located  at  the 
middle  of  the  superior  border  of  the  exstrophic  bladder.  The  cervix 
uteri  forms  a  slight  prominence  into  which  the  skin  is  attached.  It 
IS  conical  in  form.  The  cavity  of  the  uterus  is  of  nearly  the  normal 
depth,  but  rectal  examination  shows  that  in  shape  the  organ  retains 
the  peculiarities  of  childhood.  The  patient  began  to  menstruate  at 
the  age  of  fifteen  years,  and  since  then  has  been  perfectly  regular. 

Operative  Treatment  of  Ectopia  Vesicae.     (By  Prof.  Trendelen- 


MALFORMATIONS   OF  THE   BLADDER   AND  URETHRA.      695 

burg,  Bonn;  "Centralbl.  f.  Chirurg.,"  1885,  No.  49.)— Former  meth- 
ods are  criticised.  Thiersch's  flap-closm'e,  e.  g.,  does  not  secure  use  of 
the  bladder  musculature.  Trendelenburg's  first  attempts  to  secure 
direct  union  of  a  vesical  and  urethral  fisssure  by  joining  its  lateral 
edges  were  begun  five  years  ago.  His  plan  is  by  dividing  the  sacro- 
iliac synchrondrosis  on  each  side  to  mobilize  the  iliac  flanges,  and 
then  by  lateral  pressure  to  approximate  them  in  front.  Finally,  the 
fissure  thus  narrowed  is,  after  reposition  of  the  bladder  to  be  directly 
closed  by  freshening  and  suturing  its  edges.  Inferiorily  the  union 
is  to  be  continued  at  least  to  the  beginning  of  the  pars  bulbosa  ure- 
thras. Division  of  the  sacro-iliac  symphysis  is  in  childi-en  simple, 
and,  when  carefully  done,  not  dangerous.  The  child  is  laid  on  its 
belly,  and  a  finger  introduced  into  the  rectum  to  determine  the  po- 
sition of  the  incisura  ischiadica  major  and  superior  gluteal  artery. 
A  long  cut  is  then  made  over  said  symphysis ;  this  is  gradually  deep- 
ened until  strong  lateral  pressure  makes  the  pelvic  flange  yield.  On 
account  of  the  large  pelvic  vessels  it  is  not  permissible  to  cut  through 
the  deepest  portion  of  the  symphysis.  Toward  puberty  and  later  in 
life  this  operation  would  have  to  be  done  with  the  chisel,  and  would 
be  more  serious.  The  construction  of  a  continuously  active  com- 
pressing apparatus  that  could  be  tolerated  for  weeks  proved  diffi- 
cult. Tourniquet  arrangements  were  not  borne.  A  girdle  crossing 
in  front,  with  extension  weights  of  ten  to  fifteen  pounds  attached, 
has  of  late  proved  satisfactory.  Where  previously  the  spinse  sup. 
ant.  were  seventeen  centimetres  apart,  they  approached  to  within 
eleven  and  a  half  centimetres.  The  two  pubic  symphysis  stumps, 
formerly  two  inches  apart,  were  now  almost  in  contact.  It  is  well 
to  delay  the  operation  for  the  fissure  some  six  or  eight  weeks.  This 
second  operation  begins  with  freshening  the  fissure  borders  ;  he  then 
frees  the  edges  of  the  bladder  somewhat,  and  unites  with  Lem- 
bert's  sutures.  The  urethra  has  usually  been  included  in  the  oper- 
ation. A  catheter  is  left  for  a  few  days.  In  all  cases  as  yet  the 
union  to  the  extent  of  urethra  and  bladder-neck  has  subsequently 
separated.  In  a  two  and  a  half  year  old  boy  the  remainder  of  the 
bladder  held  and  the  prolapse  was  remedied.  He  thinks  that  by 
further  perfecting  his  operation  it  may  prove  successful. 

Operation  for  Congenital  Extroversion  of  the  Bladder  of  an  Infant 
Five  Days  old.— (By  H.  C.  Wyman,  M.  D.,  Detroit,  Michigan,  "  New 
York  Medical  Record,"  December  12,  1885). — From  the  umbilicus 
down  to  the  triangular  ligament  there  was  a  failure  of  development 
causing  an  extroversion  of  the  posterior  wall  of  the  bladder,  show- 
ing the  orifices  of  the  ureters  and  an  absence  of  the  dorsum  of  the 


696  DISEASES  OF  WOMEN. 

penis.  Dribbling  of  urine  from  the  ureters  was  constant.  Under 
chloroform  incisions  were  made  on  either  side  through  the  integu- 
ment and  superficial  fascia  just  forward  of  the  anterior  superior 
spine  of  the  ilium  two  inches  upward,  to  secure  relaxation ;  the 
edges  of  the  iissure  were  then  pared  and  fastened  together  M-ith 
harelip  pins  with  intermediate  sutures,  and  the  wound  dressed  with 
oxide  of  zinc  and  absorbent  cotton,  a  drainage-tube  for  the  urine  be- 
ing left  in  the  wound.  The  penis  was  not  touched,  being  reserved 
for  a  secondary  operation.  The  recovery  was  rapid  and  perfect. 
The  child  died  from  convulsions  two  months  later,  before  the  opera 
tion  upon  the  penis  could  be  performed. 


CHAPTER  XXXYIIL 

FUNCTION  OF  THE  BLADDER, 

The  function  of  the  bladder  is  to  act  as  a  reservoir  for  the  nrine, 
and  at  proper  intervals  to  expel  it  through  the  urethra.  The  filling 
of  the  organ  with  urine  is  a  comparatively  slow  and  gradual  process, 
the  fluid  entering  it  from  the  ureters  drop  by  drop,  or  in  a  very 
small  stream.  As  it  enlarges  it  does  so  in  the  direction  of  least  re- 
sistance, viz,,  laterally  and  superiorly.  The  lateral  being  its  long- 
est diameter,  it  enlarges  first  in  that  direction,  until  after  a  time  a 
limit  is  set  by  the  bony  pelvic  boundaries,  when  it  rises  from  the 
pelvis  somewhat,  thus  escaping  from  the  pressure  below.  This  move- 
ment of  the  bladder  is  facilitated  by  its  serous  surface  gliding  easily 
over  that  of  the  adjacent  organs. 

The  bladder  receives  its  nervous  supply  partly  from  the  mesen- 
teric ganglia  of  the  sympathetic,  and  partly  from  the  lumbar  portion 
of  the  spinal  cord ;  it  has  therefore  nerve-filaments  from  both  the 
cerebro-spinal  and  sympathetic  systems.  The  sphincter  vesicse  is  in 
health  in  a  state  of  tonic  contraction  which  results  in  retaining  the 
urine  in  the  bladder.  This  act  is  entirely  involuntary  and  unconscious, 
and  is  performed  in  a  perfect  manner  both  during  the  waking  and 
sleeping  hours.  When  it  is  desired  to  evacuate  the  bladder  this  sphinc- 
ter is  relaxed  by  an  act  of  the  will  conveyed  through  the  cerebro- 
spinal fibers,  but  this  relaxation  once  accomplished,  the  further  act 
by  which  the  organ  is  emptied  is  pei-formed  without  the  intervention 
of  the  will.  The  experiments  of  Kupressow  demonstrate  conclusively 
that  the  nervous  center  which  presides  over  contraction  and  relaxa- 
tion of  the  sphincter  vesicfe  is  located  in  the  lumbar  region  of  the 
spinal  cord.  And  it  may  be  accepted  that  with  other  functions  of 
a  protective  nature  the  spinal  cord  maintains  the  normal  action  of 
the  urinary  organ. 

There  has  been  considerable  discussion  among  different  authors 
as  to  whether  closure  of  the  vesical  urethral  orifice  is  a  voluntary  or 
an  involuntary  act.     Witte  and  Rosenthal  maintain  that  the  closure 

697 


698  DISEASES  OF  WOMEN. 

is  due  to  "  tonicity  from  nerve  force,"  which  resists  the  urine  press- 
ure, Kupressow  holds  the  same  view,  basing  his  opinion  on  a  series 
of  experiments  whicli  he  made,  and  further  maintains  tliat  the  sphinc- 
ter vesicae  is  at  the  neck  of  the  bladder  to  eject  the  urine  completely 
out  of  the  urethra,  in  place  of  standing  guard  and  holding  the  ves- 
ical outlet  closed.  By  others  it  is  claimed  that  this  musculo-elastic 
ring  hinders  the  entrance  of  urine  into  the  urethra,  but  that  the 
tension  of  the  bladder-walls  when  the  organ  is  filled  overbalances 
this  elasticity,  and  a  drop  of  urine  escaping  into  the  urethra  brings 
the  necessity  for  urination  to  the  senses,  and  the  act  then  becomes  a 
voluntary  one. 

It  has  been  found,  however,  in  cases  of  urethro-cystic  vaginal  fis- 
tula, where  the  upper  part  of  the  urethra  and  neck  of  the  bladder  were 
totally  destroyed,  that,  after  the  healing  of  the  parts,  the  anterior  or 
lower  end  of  the  urethra  was  practically  able  to  control  the  urine. 

The  act  of  emptying  the  bladder  is  a  very  important  and  inter- 
esting process,  and  is  not  so  simple  as  might  at  first  be  imagined. 
As  the  organ  has  three  openings  and  is  emptied  by  the  concentric 
contraction  of  its  muscular  coat,  the  urine  is  not  only  expelled 
through  the  urethra,  but  there  is  a  tendency  to  regurgitation  or 
backward  pressure  of  the  fluid  into  the  ureters.  The  backward  flow 
is  effectually  prevented  by  a  very  complete  and  interesting  arrange- 
ment. The  protection  is  threefold  :  First,  by  the  oblique  direction 
that  the  ureters  take  in  piercing  the  vesical  wall ;  second,  by  the 
two  muscular  slips  already  mentioned,  that  pass  from  the  sphincter 
vesicae  to  the  insertions  of  the  ureters.  As  the  bladder  gradually 
fills  these  slips  are  tightly  drawn,  and  thus  partially  or  wholly  close 
the  ureteric  orifices.  Moreover,  it  may  be  presumed  that  as  these 
muscular  fasciculi  have  their  origin  in  the  vesical  neck,  they  act 
most  vigorously  during  urination,  when  the  bladder  pressure  tends 
to  cause  regurgitation  into  the  ureters.  Their  greatest  use  is,  in  all 
probability,  during  the  act  of  micturition.  This  view  is  borne  out 
by  the  fact  that  these  little  muscles  are  in  a  rudimentary  condition 
in  the  female,  the  urethra  being  shorter  and  the  force  necessary  to 
empty  the  bladder  much  less  than  in  the  male ;  and  further,  by  the 
well-known  fact  that  when  the  hypertrophy  of  the  muscular  walls 
of  the  female  bladder  does  occur,  these  fasciculi  are  proportionately 
enlarged.  Third,  by  a  ligamentous  band,  not  described  in  the  text- 
books of  anatomy,  which  runs  from  one  ureteric  opening  to  the 
other,  inclosing  their  vesical  ends,  and  is  known  as  the  inter-ureteric 
ligament.  Its  mode  of  action  is  this :  As  the  bladder  gradually 
fills,  the  openings  of  the  ureters  are  carried  farther  apart,  and  witli 


FUNCTION  OF   THE   BLADDER.  699 

them  the  ends  of  the  ligament.  Being  elastic,  it  yields  to  a  certain 
extent,  and  after  a  time,  being  able  to  yield  no  more,  pulls  upon 
both  openings,  closing  them  more  or  less  completely.  During  uri- 
nation the  tension  of  the  ligament  gradually  decreases,  and  then  the 
muscular  fasciculi  and  the  oblique  direction  in  which  the  ureters 
enter  the  bladder  come  into  play,  the  ligament  being  of  use  only 
during  filling  and  distention. 

If  from  any  cause  the  bladder  is  not  emptied  at  the  proper  time, 
the  organ  is  not  only  injured  by  overdistention,  but  more  serious  re- 
sults may  follow  if  the  retention  continues  for  some  time  ;  although  the 
bladder  is  too  full  to  receive  any  more  urine,  the  kidneys  continue  to 
secrete  until  not  only  the  bladder,  but  also  the  ureters,  renal  pelves, 
and  kidney  tubes  become  overfilled.  When  the  pressure  on  the  uri- 
nary side  of  the  Malpigbian  tuft  equals  that  of  the  blood-stream  in  the 
glomerulus,  secretion  of  urine  at  once  ceases,  and  we  have  a  mechan- 
ical suppression.  After  death  the  bladder,  ureters,  and  renal  pelves 
are  found  to  be  greatly  distended,  and  the  kidney  pale,  of  a  bluish, 
pearly  color  in  the  cortex,  and  oozing  urine  from  the  cut  surface. 

Maas  and  Punier  (New  York  Medical  Eecord,  October  1,  1881) 
have  performed  experiments  on  animals  and  men  which  demon- 
strate to  their  satisfaction  that  the  bladder,  whether  health}^  or  dis- 
eased, as  well  as  the  urethra,  possesses  the  faculty  of  absorption  in  a 
greater  or  less  degree,  varying  with  the  substance  used.  Their 
methods  when  experimenting  on  animals  were  as  follows :  The 
bladder  was  fully  exposed,  both  ureters  tied  about  half  an  inch 
above  their  termination,  then  divided  above  the  ligatures,  and  the 
urine  conducted  outside  of  the  body  by  means  of  glass  cannulas  in- 
troduced into  the  central  ends.  The  bladder  was  then  evacuated  by 
a  catheter  through  which  the  solution  experimented  with  was  in- 
jected, the  catheter  withdrawn,  and  a  ligature  drawn  tightly  around 
the  urethra  between  the  prostate  gland  and  the  neck  of  the  bladder ; 
sometimes  after  tying  the  ureters  and  urethra  the  bladder  was  emp- 
tied by  a  Pravaz  syringe,  the  medicated  solution  injected  through 
the  cannula  of  the  latter,  and  the  puncture  closed  by  ligature. 

In  a  second  series  of  experiments  the  abdominal  cavity  was  not 
opened,  but  after  drawing  off  the  urine  the  solution  was  injected 
through  the  catheter,  and  the  mouth  of  the  latter  plugged.  The 
substances  used  were  ferrocyanide  of  potassium,  salicylate  of  soda, 
cyanide  of  potassium,  strychnine,  atropine,  curare,  apomorphia,  and 
pilocarpin.  All  of  these  substances  were  absorbed,  but  some  so 
slowly  that  their  physiological  action  was  not  manifested ;  thus  atro- 
pine seemed  to  have  no  effect  upon  the  animal,  but  a  small  quantity 


700  DISEASES  OP  WOMEN. 

of  its  uriue  collected  during;  the  continuance  of  the  experiment  and 
instilled  into  the  eye  of  another  animal  rapidly  caused  dilatation  of 
the  pupil.  The  diseased  bladder  was  also  found  capable  of  absorb- 
ing the  same  substances. 

In  their  experiments  on  man,  Maas  and  Punier  used  iodide  of  po- 
tassium and  pilocarpin.  As  regards  the  excretion  of  the  foi-mer,  they 
call  attention  to  the  fact  that  in  some  individuals  it  rapidly  passes  off 
by  the  urine,  in  others  by  the  saliva,  and  in  others  by  only  one  of 
these  paths  to  the  exclusion  of  the  other.  The  method  used  was  the 
following  :  Taking  only  individuals  with  healthy  bladders,  the  latter 
were  evacuated  by  a  Nelaton  catheter,  after  which  in  twenty-eight 
cases  they  injected  fifty  grammes  of  a  ten-per-cent  solution  of  iodide 
of  potassium,  following  this  up  in  thirteen  other  cases  with  an  injec- 
tion of  one  or  two  centigrammes  of  muriate  of  pilocarpin  half  an  hour 
later.  The  iodide  was  detected  in  the  saliva  in  fifty-seven  per  cent  of 
the  first  and  seventy-seven  per  cent  of  the  second  series,  but  usually 
in  small  quantities  only.  The  diseased  bladder  was  found  to  absorb 
much  more  promptly  ;  iodide  of  potassium  was  detected  in  the  saliva 
when  only  2*0  were  used.  A  solution  of  0*4  morphine  in  2*0  of  dis- 
tilled water  used  in  this  way  acted  very  plainly  as  an  anodyne.  Pilo- 
carpin made  up  into  a  bougie  with  cocoa-butter,  and  introduced  into 
the  urethra  (both  healthy  and  diseased),  manifested  its  specific  ejBfects. 

L.  Schafer  found  that  after  producing  vesico- vaginal  fistulas  in  ani- 
mals there  was  increase  of  from  two  to  three  per  cent,  and  sometimes 
from  four  to  five  per  cent,  in  the  amount  of  urine  passed  over  that 
passed  before  the  fistulas  were  made ;  and  he  feels  convinced  that 
under  normal  conditions  of  urinary  secretion  the  amount  of  urine  in 
the  bladder  is  gradually  diminished  by  a  slight  though  regular  absorp- 
tion of  its  watery  elements.  If  this  be  true,  we  may  look  to  a  too 
rapid  absorption  as  one  of  the  causes  of  gravel  and  urinary  calculi. 

On  the  other  hand,  however,  Susini  found  that  after  injecting 
potassium  iodide  and  belladonna  into  his  own  bladder  and  retaining 
them  for  many  hours,  no  trace  of  the  former  was  found  in  the  saliva, 
and  no  appearance  of  the  specific  action  of  the  latter  was  made  mani- 
fest. Ailing  agrees  with  Susini,  and  the  experiments  of  P.  Dubelt 
also  support  this  view.  After  careful  consideration  of  the  evidence 
^ro  and  con^  I  am  strongly  inclined  to  the  view  that  the  bladder 
does  not  absorb  anything,  save  possibly  a  little  water,  unless  its 
epithelial  surface  is  displaced  or  destroyed.  "When  abrasion  does 
occur,  absorption  is  rapid  and  its  effects  marked.  The  fact  that  the 
mucous  membrane  of  the  bladder  is  able  to  absorb  liquids  after  ero- 
sion of  its  epithelium  throws  much  light  on  the  cause  of  some  of 


FUNCTION  OP   THE   BLADDER.  YOl 

those  peculiar  constitutional  symptoms  accompanying  chronic  cysti- 
tis, and  known  by  some  authors  as  ammonsemia. 

The  inner  surface  of  the  bladder  is  lubricated  by  a  very  thin 
secretion  of  mucus.  This  can  be  demonstrated  by  putting  some 
fresh,  normal  urine  in  a  clean  bottle.  In  a  short  time  a  slight  hazy 
cloud  will  settle  to  the  bottom.  When  examined  microscopically  it 
will  be  found  to  consist  of  a  few  epithelial  scales  and  mucous  fibrillse 
— long,  fine,  and  often  interlacing.  In  disease  this  secretion  becomes 
greatly  increased,  and  is  then  thick,  viscid,  and  ropy.  The  normal 
secretion  when  tested  chemically  is  found  to  contain  an  abundance 
of  the  earthy  and  alkaline  phosphates. 

A  healthy  woman  urinates  from  four  to  six  times  in  every  twenty- 
four  hours,  and  passes  in  all  from  thirty -five  to  sixty  ounces  of  urine, 
the  average  being  about  forty-five  ounces.  The  amount  passed  varies 
much  with  the  season  of  the  year,  more  being  passed  in  winter  than 
in  summer ;  it  varies  also  with  the  amount  of  fluid  ingesta,  rest,  and 
exercise.  Neither  limpid  nor  concentrated  urine  are  well  borne  by 
the  bladder. 

The  pressure  of  the  urine  in  the  bladder  being  of  importance  in 
both  health  and  disease,  I  deem  it  advisable  to  give  here  the  results 
of  some  experiments  by  Schatz,  Odelbrecht,  Hegar,  and  Dubois. 
These  experiments  were  made  with  the  manometer,  an  instrument 
which  by  means  of  a  column  of  mercury  may  be  adapted  to  register 
the  exact  pressure  in  the  bladder. 

They  found  the  pressure  to  be  from  twelve  to  sixteen  inches  while 
standing ;  in  the  recumbent  posture  it  was  only  from  four  to  six  inches. 
The  pressure  in  the  recumbent  position  Dubois  believed  to  be  due 
not  to  visceral  pressure  from  above,  but  to  the  natural  tonicity  of 
the  distended  organ  ;  for  in  the  cadaver,  after  removing  the  other 
viscera,  the  pressure  in  the  bladder  indicated  four  inches,  plainly 
due  to  the  elasticity  of  the  organ  itself.  The  same  has  been  observed 
in  cystocele,  in  which  the  visceral  pressure  is  also  absent. 

The  pressure  is  about  the  same  in  both  sexes  and  at  all  ages.  It 
was  found  to  rise  from  one  half  to  one  inch  with  each  inspiration, 
and  to  fall  about  the  same  with  each  expiration.  In  laughing, 
coughing,  etc.,  it  rose  as  high  as  from  twenty  to  sixty  inches.  In 
diseases  of  the  spinal  cord,  such  as  myelitis,  and  after  injuries  to 
the  vertebrae,  Dubois  found  a  marked  decrease  in  bladder  pressure. 

These  curious  observations  on  the  varying  degrees  of  pressure 
arising  from  change  of  posture  are  not  without  value.  They  help 
one  to  understand  why,  in  some  diseases  of  the  bladder,  patients 
should  maintain  the  recumbent  position. 


CHAPTER  XXXIX. 

FTTNCTIONAL    DISEASES    OF    THE   BLADDER, 

It  has  been  the  rule  among  pathologists  to  class  under  the  head 
of  functional  diseases  all  those  in  which  no  lesion  of  structure  was 
discoverable  in  the  organs  concerned.  Although  we  are  still  obliged 
to  accept  this  nomenclature,  the  progress  of  jjathological  knowledge 
in  the  past  few  years  has  weeded  out  many  of  the  so-called  functional 
affections :  and  as  this  knowledge  advances,  and  new  and  efficient 
means  for  observation  and  study  arise,  we  shall  be  able  to  root  out 
many  more,  thus  doing  away  with  much  of  the  vagueness  and  uncer- 
tainty in  which  this  class  of  affections  is  shrouded.  But  even  with 
the  improved  facilities  for  diagnosis  at  our  command,  there  are  still 
many  diseases  in  this  list.  Owing  to  the  obscurity  at  present  sur- 
rounding the  subject  of  reflex  or  sympathetic  disorders,  i.  e.,  the 
abnormal  condition  of  an  organ  or  organs,  near  or  distant,  affecting 
the  function  or  nutrition  of  another  organ,  we  are  obliged  to  put 
these  affections  in  this  class  also.  Under  this  head  then  will  be 
considered : 

I.  Derangements  of  function  in  which  there  is  no  recognizable 
organic  lesion. 

II.  Derangements  of  function  due  to  diseases  of  the  nutritive 
and  nervous  systems,  and  to  abnormal  conditions  of  the  urine  re- 
sulting therefrom. 

III.  Derangements  of  function  due  to  inflammatory  and  other 
affections  of  the  pelvic  organs,  such  as  metritis  and  pelvic  perito- 
tonitis. 

It  will  be  observed  that  in  this  arrangement  of  the  subject,  al- 
though a  number  of  structural  diseases  are  considered,  they  all 
stand  in  a  causative  relation  to  the  disturl)ed  action  of  the  bladder, 
tlie  latter  being  free  from  any  organic  lesion,  and  only  disturbed  in 
the  discharge  of  its  duty  by  influences  outside  of  itself. 

Before  discussing  these  functional  disorders  in  detail,  it  will  be 

702 


FUNCTIONAL  DISEASES  OF  THE   BLADDER.  Y03 

necessary  to  fix  clearly  in  the  mind  their  various  manifestations ; 
these  are :  frequent  urination,  or  polyuria ;  diflicult  urination  and  re- 
tention, or  ischuria  ;  painful  urination,  or  dysuria  ;  pain  after  urina- 
tion, or  vesical  tenesmus;  and  incontinence  of  urine,  or  enuresis. 
These  deranged  actions  may  also  be  due  to  organic  diseases  of  the 
bladder,  but  they  will  at  present  only  be  discussed  in  connection 
with  the  three  classes  of  functional  derangements  of  that  organ  just 
referred  to  : 

I.  Derangements  of  function  in  which  there  is  no  recognized 
organic  lesion.  There  are  five  of  these  derangements  which  demand 
special  consideration, 

1.  Neuroses,  pure  and  simple. 

2.  Derangements  due  to  hysteria. 

3.  Derangements  due  to  disorders  of  the  sexual  function, 

4.  Derangements  due  to  malaria. 

5.  Derangements  due  to  ovarian  affections. 

1.  Neuroses. — By  this  term  I  refer  to  purely  nervous  affections 
of  this  organ.  They  are  rather  rare,  it  is  true,  but  that  they  do  ex- 
ist there  is  no  doubt,  for  there  are  certain  conditions  that  seem  to 
depend  on  no  other  known  pathological  cause. 

We  learn  from  the  books  that  vesical  neuralgia  is  of  this  class. 
It  is  known  by  a  variety  of  names,  each  taking  as  its  key-note  some 
peculiar  manifestation  or  symptom,  as  irritable  bladder,  cystospasm, 
cystoplegia,  and  neuralgia  vesicae. 

The  term  irritability  so  commonly  used  in  speaking  of  the 
healthy  organ  must  not  be  confounded  with  the  condition  known  as 
irritable  bladder.  The  former  refers  to  a  certain  property  that  the 
viscus  possesses,  by  means  of  which  it  is  able  to  respond  to  certain 
stimuli,  while  the  latter  refers  to  an  abnormal  condition  of  sensation^ 
viz.,  super-sensibility,  or  hyperpesthesia. 

2.  Derangements  due  to  Hysteria. — Hysteria  holds  a  prominent 
place  among  the  causes  of  functional  derangement  of  the  bladder, 
the  vesical  affection  being  probably  only  a  fragment  of  a  general 
neurosis.  Acute  and  chronic  diseases  of  the  brain  and  spinal  cord 
also  produce  various  vesical  difficulties  of  this  nature,  but  these  will 
be  discussed  under  another  class.  Any  one  who  has  suffered  the 
mortification  of  an  involuntary  evacuation  of  m-ine  from  fear,  will 
understand  how  the  brain  and  nervous  system  can  influence  the 
bladder. 

In  the  variety  of  conditions  grouped  under  the  head  of  hysteria, 
it  is  often  observed  that  frequent  urination  is  a  prominent  symptom. 
The  cause,  in  many  cases,  is  the  peculiar  character  of  the  urine  se- 


704  DISEASES  OF  WOMEN. 

creted  in  this  disturbed  condition  of  the  nervous  system.  The  lim- 
pid urine  of  hysterical  patients  is  deficient  in  solids,  the  watery  por- 
tion being  greatly  in  excess.  This  unnatural  composition  renders 
the  urine  irritating  to  the  bladder  so  that  it  can  not  be  long  retained. 
The  quantity  of  urine  secreted  is,  at  certain  times,  excessive,  which, 
together  with  its  irritating  quality,  renders  urination  necessarily 
very  frequent. 

But  apart  from  the  frequent  urination  which  occurs  in  severe 
attacks  of  hysteria  due  to  the  conditions  just  mentioned,  cases  are 
often  seen  of  frequent  micturition  which  can  only  be  accounted  for 
by  the  state  of  the  nerves  which  govern  the  action  of  the  bladder. 
When  the  quantity  and  composition  of  the  urine  are  normal,  and  the 
patient  can  retain  it  without  pain  or  distress  during  the  night,  but 
has  to  pass  it  every  hour  or  two  during  the  day,  it  may  safely  be 
presumed  that  the  trouble  is  functional,  and  due  to  a  disordered 
state  of  the  nervous  system.  The  only  condition  which  resembles 
this  history  is  occasionally  seen  in  prolapsus  uteri,  the  patient  being 
free  from  trouble  while  reclining,  but  having  to  urinate  frequently 
when  in  the  erect  position. 

Hysterical  patients  frequently  suffer  from  retention  of  urine. 
Some  of  them  complain  for  a  time  of  difficulty  in  emptying  the 
bladder,  and  tinally  fail  to  do  so  altogether.  At  other  times  they 
suddenly  find  that  they  can  not  urinate.  There  are  conflicting 
views  regarding  the  cause  of  this  retention,  some  believing  that  such 
patients  can  not  urinate,  and  others  that  they  will  not.  Those  who 
believe  that  the  trouble  is  feigned  and  not  real,  do  so  on  the  ground 
that  in  this  morbid  state  of  the  nervous  system  the  patients  enjoy 
catheterization,  which  would  be  distressing  to  any  one  of  healtliy 
mind  and  body.  Others  claim  that  in  the  extreme  sexual  excite- 
ment which  occurs  in  some  cases  of  hysteria,  the  chronic  erection 
of  the  clitoris  makes  pressure  upon  the  urethra,  and  prevents  the 
flow  of  the  urine  through  the  canal  which  is  at  that  time  com- 
pressed. 

1  am  satisfied  that  both  kinds  of  cases  occur.  There  are  those 
who  complain  of  retention  when  they  know  that  the  doctor  will  use 
the  catheter,  but  they  can  urinate  easily  when  they  please.  Others 
I  have  seen  who  were  suffering  from  excessive  and  painful  disten- 
tion of  the  bladder  and  would  have  gladly  relieved  themselves  if 
they  could. 

3.  Derangements  due  to  Disorders  of  the  Sexual  Function. — An- 
other class  which  resembles  the  hysterical  j^atients  in  the  frequency 
of  urination,  but  differs  in  every  other  respect,  is  found  in  those 


FUNCTIONAL  DISEASES   OF   THE  BLADDER.  T05 

who  suffer  from  the  habit  of  masturbation.  The  constant  conges- 
tion and  irritability  of  the  pelvic  organs,  caused  and  kept  up  by  the 
unnatural  and  excessive  exercise  of  the  sexual  function  give  rise  to 
frequent  urination.  Such  patients  complain  of  general  weakness, 
which  is  not  accounted  for  by  any  organic  disease  of  the  general 
system.  Nor  is  there  disease  of  the  bladder ;  it  is  simply  enfeebled 
and  irritable  like  the  rest  of  the  pelvic  organs.  To  make  a  correct 
and  positive  diagnosis  in  such  cases  is  by  no  means  easy,  because  it  ne- 
cessitates our  detecting  the  habit  of  masturbation,  and  this  is  usually 
one  of  the  most  difficult  tasks  for  the  diagnostician.  It  is  not  al- 
ways prudent  to  question  the  patient  regarding  the  habit ;  and  even 
when  that  is  done  they  frequently  fail  to  comprehend  the  question, 
or  they  answer  falsely  in  the  negative.  The  physician  is  thus  gen- 
erally left  to  guess  at  the  truth  of  the  matter. 

The  symptoms  developed  by  masturbation  are  depression  of  the 
nervous  system,  manifested  by  lassitude,  sadness,  or  emotional  ex- 
pressions of  joy  and  sorrow,  those  affected  with  this  habit  being  easily 
affected  to  smiles  or  tears.  The  eyes  are  dreamy  and  heavy,  and  the 
pupils  dilated.  Such  subjects  are  excitable,  irritable,  and  easily  ex- 
hausted. They  often  have  headaches.  Nutrition  is  apparently  good 
in  some  cases,  as  is  shown  by  the  fair  supply  of  flesh ;  still,  they  often 
suffer  from  acute  indigestion,  although  at  times  the  appetite  is  re- 
markably good.  The  bowels  are  usually  constipated,  and  the  mus- 
cles soft  and  flahby.  The  exhalations  from  the  skin  are  some- 
times changed,  so  that  a  peculiar  odor  is  noticeable  about  such  persons- 
This  odor  can  not  be  described,  but,  when  once  recognized,  is  easily 
remembered. 

In  this  variety  of  functional  derangement  of  the  bladder,  as  well 
as  in  all  the  other  varieties  of  neurotic  affections,  the  symptoms  vary 
in  severity  to  a  great  extent  in  the  same  individual.  The  trouble  is 
by  no  means  regular  and  constant  in  its  manifestations,  as  in  organic 
diseases.  Whatever  disturbs  the  nervous  system  will  increase  the 
disorder.  The  rule  is  that  frequent  urination  is  the  prominent  symp- 
tom, but  occasionally  painful  micturition  is  complained  of.  It  is 
then  simply  a  slight  scalding  pain,  experienced  when  the  urine  is 
passing  over  the  irritable  or  chafed  mucous  membrane  about  the 
meatus  urinarius. 

4.  Derangements  due  to  Malaria. — Another  cause  which  I  believe 
acts  through  the  nervous  system  is  malaria.  The  effect  of  malarial 
poison  on  the  bladder  and  urethra  is  very  peculiar.  The  trouble 
produced  in  this  way  has  been  called  urethral  fever,  and  is  described 
as  an  inflammation  of  the  mucous  membrane  of  that  canal.  It  might 
4n 


706  DISEASES   OF   WOMEN. 

more  properly  be  called  malarial  fever  of  the  urethra.  As  I  have 
observe,d  this  affection,  the  bladder  and  urethra  are  usually  both 
affected,  but  I  do  not  consider  the  disease  one  of  a  well-defined  in- 
flammatory character.  There  are  usually  symptoms  of  malaria  pres- 
ent, but  not  necessarily  chill  and  fever.  On  the  contrary,  I  believe 
that  I  have  observed  the  affection  more  frequently  in  remittent  than 
in  intermittent  fever,  and  very  often,  where  the  constitutional  symp- 
toms were  not  more  than  a  shght  derangement  of  the  digestive 
organs,  with  moderate  elevation  of  temperature  in  the  after-part  of 
the  day. 

The  symptoms  vary,  but  usually  are  as  follows  :  The  patient  com- 
plains of  frequent  desire  to  urinate,  and  some  vesical  tenesmus ;  se- 
vere burning  pain  on  passing  water,  with  stinging  and  burning  in 
the  urethra  after  urination.  The  history  of  such  cases  resembles 
acute  gonorrhcjeal  urethritis  so  far  as  the  abruptness  of  the  attack  and 
the  tenderness  and  pain  of  the  urethra  are  concerned,  but  there  is 
usually  no  discharge,  or,  at  least,  very  little.  In  many  cases  the 
suffering  is  greatest  in  the  afternoon  and  early  part  of  the  night. 
Under  proper  treatment  the  disease  disappears  as  promptly  as  it 
comes  on. 

5.  Derangements  due  to  Ovarian  Affections. — In  disease  of  the 
ovaries  we  sometimes  find  that  the  bladder  suffers  very  much  from 
deranged  nerve  action.  The  clearest  and  best  account  of  this  form 
of  functional  bladder  troublo  is  given  by  Fothergill  in  his  paper  on 
"  Ovarian  Dyspepsia,"  published  in  the  "  American  Journal  of  Ob- 
stetrics," January,  1878.  In  speaking  of  the  derangement  of  the 
stomach  and  pelvic  organs,  he  says  :  '"  It  soon  became  clear  that  there 
was  some  condition  existing  which  stood  in  a  causative  relation  to 
both  the  dyspepsia  and  the  uterine  disturbance.  That  condition  was 
quickly  seen  to  be  a  state  of  vascular  excitement  in  one  or  both  ova- 
ries, usually  the  left  ovary.  This  condition  Barnes  terms  '  oophoria.' 
In  this  state  there  is  always  more  or  less  pain  constantly  in  the  iliac 
fossa,  more  rarely  on  the  right,  much  aggravated  at  the  catamenial 
periods,  when  the  pain  shoots  from  the  turgid  ovary  down  the  thigh 
of  the  corresponding  side  along  the  genito-cniral  nerve.  This  pain- 
ful state  is  otherwise  known  as  '  ovarian  dysmenorrhoea.'  When 
pressure  is  made  over  this  tender  ovary  during  the  catamenial  flow, 
acute  pain  is  experienced.  Pressure  also  elicits  pain  during  the  inter- 
menstrual interval.  At  the  same  time  that  acute  pain  is  felt,  evi- 
dence is  furnished  of  emotional  parturbation ;  the  patient  feels  as  if 
about  to  faint,  or  'feels  queer  all  over,'  as  some  express  it,  and  the 
changes  in  the  patient's  countenance  speak  of  something  more  than 


FUNCTIONAL  DISEASES  OF  THE   BLADDER.  707 

more  pain,  pure  and  simple.  It  is  evident  there  is  a  wave  of  nerve- 
perturbation  set  np,  which  excites  more  than  the  sensation  of  pain. 
Commonly  the  patient  feels  sick  after  the  momentary  pressure,  and 
asks  to  be  permitted  to  sit  down,  alleging  that  she  feels  sick  and 
faint.  If  a  careful  physical  examination  be  made,  it  will  be  found 
that  there  is  an  enlarged  and  tender  ovary,  which  may  sometimes  be 
caught  betwixt  the  linger  in  the  vagina  and  the  lingers  of  the  other 
hand  applied  to  the  abdominal  wall  of  the  ovary.  Such  manipula- 
tion elicits  manifestations  of  acute  suffering  from  the  patient.  Fre- 
quently the  rectus  muscle  over  the  tender  ovary  is  hard  and  rigid, 
so  as  to  place  the  organ  as  perfectly  at  rest  as  is  possible ;  just  as  we 
see  the  rectus  to  stiffen  and  become  rigid  over  the  liver  when  there 
is  an  hepatic  abscess,  and  thus  to  secure  rest,  as  regards  movement, 
for  that  viscus.  .  .  . 

"  jN^ot  rarely,  too,  there  is  set  up  a  very  distressing  condition,  viz., 
that  of  recurring  orgasm.  This  occurs  most  commonly  during  sleep 
— '  the  period  par  excellence  of  reflex  excitability.'  In  more  aggra- 
vated cases  it  also  occurs  during  the  waking  moments,  and  this  it 
does  without  any  reference  to  psychical  conditions. 

"  The  centers  of  the  pelvic  viscera  lie  near  together  in  the  cord, 
and  the  condition  of  one  is  readily  communicated  to  another.  The 
brief  recurrent  orgasm  affects  the  bladder-centers,  and  the  call  to 
make  water  is  sudden  and  imperative,  and  must  be  attended  to  at 
once,  or  a  certain  penalty  be  paid  for  non-attention.  This  last  is  not 
a  common  condition,  fortunately,  but  it  is  a  source  of  great  suffering, 
bodily  and  mental,  when  it  does  occur.  The  condition  of  the  ovary 
also  acts  reflexly  upon  the  uterus,  and  keeps  it  in  a  state  of  persistent 
erection  and  high  vascularity,  with  the  normal  phenomena  attendant 
thereupon." 

It  is  evident  that  this  form  of  bladder  trouble  can  only  be  re- 
lieved by  treatment  of  the  ovarian  disease,  for  which  bromide  of 
potassium  and  counter-irritation  are  very  serviceable,  with,  of  course, 
attention  to  the  general  health. 

Symptomatology. — In  all  of  these  nervous  affections  of  the  urin- 
ary organs,  pain  and  a  feeling  of  weight  and  uneasiness  in  the  region 
of  the  bladder  are  usually  present.  Still,  the  most  constant  and  dis- 
tressing symptom  is  the  frequent  and  painful  desire  to  micturate, 
which  the  patient  tries  to  relieve  by  frequent  urination,  a  few  drops 
only  being  passed  at  a  time.  Of  course,  there  are  varying  grades  of 
this  affection,  in  some  of  which  these  symptoms  are  by  no  means  so 
troublesome.  In  some  extreme  cases,  when  a  little  urine  collects  in 
the  bladder,  the  pain  and  irritability  are  so  intense  that  it  is  spurted 


Y08  DISEASES  OF  WOMEN. 

out  by  a  very  forcible  and  painful  contraction  of  the  organ.  The 
sense  of  weight  and  bearing  down  are  most  intense  in  the  upright 
position.  The  pains  may  be  confined  to  the  neck  or  base  of  the 
bladder,  or  they  may  shoot  in  all  directions.  The  pain  in  micturition 
may  be  present  at  the  beginning,  but  is  usually  most  severe  during 
and  after  the  completion  of  the  act. 

The  local  pain  and  distress,  with  the  frequent  urination  and  un- 
rest, react  upon  the  general  nervous  system,  thereby  greatly  aggra- 
vating the  original  disorder.  This  lowered  systemic  condition  in 
turn  affects  the  local  disorder,  and  so  the  one  is  continually  aggra- 
vating the  other.  In  this  way  the  patient,  if  not  relieved,  goes  on 
from  bad  to  worse,  until  the  host  of  phenomena  characteristic  of 
nervous  prostration  and  general  ill-health  are  developed. 

In  certain  cases  the  sufferers  are  by  no  means  so  badly  circum- 
stanced, but  time  and  neglect  tend  to  produce  these  results  sooner 
or  later.  In  some  cases,  again,  the  suffering  gradually  disappears, 
and  the  patient  is  restored  to  health  mthout  much  aid  from  treat- 
ment.    The  trouble  appears  to  wear  itself  out. 

Diagnosis. — The  symptoms  I  have  given  are  by  no  means  pathog- 
nomonic of  these  affections,  the  same  being  produced  by  organic 
disease  of  the  bladder,  calculi,  and  various  other  causes.  The  diag- 
nosis must  be  made  by  exclusion.  The  first  thing  to  do  is  to  make 
a  careful  microscopical  and  chemical  analysis  of  the  urine.  Not  only 
can  local  organic  trouble  be  thus  eliminated,  but  important  knowl- 
edge as  to  the  state  of  the  general  system  obtained. 

If  no  urinary  abnormality  is  discovered,  a  careful  external  and 
internal  examination  of  the  oro-an  itself  should  be  made.  A  fiuffer 
should  first  be  passed  into  the  vagina,  and  an  endeavor  made  to  ascer- 
tain, by  pressure  on  the  vesico-vaginal  septum,  whether  there  is  any 
abnormal  sensitiveness  of  the  vesical  base  or  neck,  or  of  both.  Then 
the  sensibility  of  the  mucous  membrane  should  be  tested  by  the  in- 
troduction of  a  sound. 

If  sufficient  cause  be  not  found  in  either  the  urine  or  the  bladder, 
the  case  may  be  set  down  as  one  of  pure  neurosis,  to  be  treated  as  I 
shall  hereafter  describe.  Systemic  conditions,  such  as  hysteria  or 
chlorosis,  should  be  considered,  as  they  ]>oint  to  a  tendency  to  neu- 
rotic difficulties,  liable  to  be  localized. 

Proyno-ns. — As  a  rule,  the  prognosis  is  favorable.  This,  how- 
ever, is  not  always  the  case.  The  longer  the  affection  has  lasted,  the 
more  difficult  it  is  to  cure.  Most  cases  may  be  cured  in  a  few  wrecks' 
time,  and  even  the  most  obstinate  in  a  few  months.  The  danger  to 
the  patient  lies  in  the  fact  that  continuance  of  the  disorder  is  liable 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  ^09 

to  bring  on  an  organic  lesion,  and,  whether  this  results  or  not,  the 
reaction  on  the  general  system  tends,  in  the  worst  cases,  to  produce 
hypochondriasis  or  even  melancholia. 

Causation. — These  nervous  affections  of  the  bladder  occur  most 
frequently  in  those  of  the  nervous  temperament.  A  highly  devel- 
oped nervous  system  predisposes  one  to  nervous  affections  of  all 
kinds.  Especially  is  this  the  case  if  the  subject  is  not  well  sustained 
by  a  vigorous  nutritive  system.  Those  in  whom  the  emotional  ele- 
ments predominate  in  the  mental  composition  are  more  liable  to 
nervous  affections  of  the  bladder  than  those  of  the  more  intellectual 

type- 

The  exciting  causes  include  all  influences  which  depress  or  ex- 
haust the  nervous  system.  Mental  taxation  or  excitement  which 
tends  to  increase  the  excitability  of  the  nervous  system  may  derange 
the  function  of  the  bladder.  Constitutional  diseases  which  lower  the 
tone  of  the  w^hole  organization  also  tend  to  produce  the  affections 
now  under  discussion. 

It  is  not  possible  to  give  any  satisfactory  explanation  of  the  reason 
why  the  innervation  of  the  bladder  becomes  deranged  in  some  per- 
sons from  causes  which  are  in  others  inoperative.  It  may  be  that 
those  who  are  most  susceptible  to  this  cause  are  so  because  of  some 
inherited  sensitiveness  of  the  pelvic  organs  which  responds  to  the 
disturbing  influences.  This  appears  to  be  the  case  with  those  who 
suffer  from  irritation  of  the  bladder  caused  by  ovarian  disease.  This 
is  apparent  from  the  fact  that  one  affected  with  disease  of  the  ovaries 
will  suffer  from  derangement  of  the  function  of  the  stomach,  while 
another  having  a  similar  ovarian  affection  will  suffer  most  from  fre- 
quent urination. 

Regarding  the  causative  relations  of  malaria  to  irritation  of  the 
bladder,  all  that  can  be  said  at  the  present  time  is  that  this  materies 
niorhi  appears  to  act  upon  that  viscus  through  the  nervous  system. 

Treatment. — This  may  be  classed  as  general  and  local.  In  pure 
neuroses,  attention  should  be  first  directed  to  improving  the  general 
condition  of  the  patient.  Cheerful  company  should  be  provided  at 
meals  and  at  other  times,  and  there  should  be  exercise  suited  to  the 
strength  of  the  patient,  daily  ablution,  and  proper  regulation  of  diet. 
This  latter  should  be  simple  and  nourishing,  and  of  a  kind  calculated 
to  produce  as  little  urea  and  urinary  solids  as  possible.  In  cases 
where  the  urine  is  limpid,  the  opposite  course  is  to  be  pursued. 
Pastry,  irritatmg  condiments,  and  stimulants,  except  in  rare  cases, 
should  be  prohibited.  The  exception  to  this  is  where  a  condition 
of  the  system  calling  for  stimulation  exists.    In  such  cases  the  irrita- 


710  DISEASES   OF  WOMEN. 

tion  of  the  bladder  produced  by  their  use  may  be  more  than  counter- 
balanced by  the  good  they  do  the  general  system.  Tea  is  better  than 
coffee,  but  neither  is  to  be  used  in  any  great  quantity. 

The  condition  of  the  urinary  secretion  must  be  carefully  watched, 
and  any  abnormality  quickly  and  judiciously  corrected.  Where  there 
is  any  tendency  to  excessive  acidity,  the  effervescing  waters,  rich  in 
carbonic-acid  gas,  will  be  found  of  use. 

The  bowels  should  be  kept  moderately  well  open,  but  should 
never  be  irritated  with  active  cathartic  agents. 

Tonics  and  medicinal  stimulants  are  often  of  great  value  when 
judiciously  exhibited.  Strychnia  in  very  small  doses  does  not,  as 
might  be  supposed,  aggravate  the  irritable  condition  of  these  organs. 
The  nerve-tone  being  below  par,  strychnia,  by  gradually  increasing 
it,  is  of  great  service.  In  large  doses  it  is  undoubtedly  hurtful,  and 
should  never  be  long  continued.  Quinine,  iron,  and  the  various  sim- 
ple and  compound  vegetable  bitters  act  well  in  the  cases  where  their 
exhibition  is  indicated. 

If  the  irritation  is  extreme,  various  soothing  emulsions  and  de- 
coctions may  be  given  by  the  mouth.  Of  these,  preparations  of 
marshmallow,  triticum  repens,  acacia,  pareira  brava,  and  buchu  act 
well.  Emulsio-amygdalse  is  much  used  and  highly  recommended  by 
the  German  authors. 

Some  objections  have  been  raised  to  the  use  of  these  drugs  on 
the  score  that  they  increase  the  flow  of  urine,  thus  aggravating  the 
local  irritability.  The  fact  is,  however,  that  the  presence  of  fairly 
normal  urine  in  the  bladder  in  moderate  quantity  seems  to  relieve 
rather  than  increase  its  irritable  condition. 

The  local  treatment  may  be  as  follows :  A  cupful  of  M-arm  ho])- 
tea,  containing  from  twenty  to  forty  drops  of  laudanum,  may  be 
injected  into  the  rectum.  Suppositories  containing  opium  may  often 
be  used  with  benefit.  With  the  opium  or  morphine  in  the  supposi- 
tories may  be  combined  belladonna,  atroijine,  or  hyoscyamus.  Mor- 
phine in  the  form  of  Magendie's  solution  may  be  injected  directly 
into  the  bladder.  There  seems  to  be  no  especial  advantage  in  this 
mode  of  administering  anodynes,  hypodermic  injections  of  the  drug 
acting  as  well,  if  not  better.  Emulsions,  decoctions,  and  infusions 
of  cannabis  Indica,  hyoscyamus,  belladonna,  and  other  like  drugs 
may  be  used  by  the  mouth,  as  the  case  may  require. 

Good  effects  have  followed  the  use  of  rectal  injections  containing 
chloral  hydrate  (grains  15  to  water  ^i  or  3  ij).  It  may  also  be  given 
by  the  mouth,  but  does  not  usually  act  so  quickly  or  have  such  a 
direct  local  effect. 


FUNCTIONAL  DISEASES  OF   THE  BLADDER.  711 

The  injection  into  the  bladder  of  a  sohition  containing  morphine, 
followed  by  cauterization  of  the  mucous  membrane,  is  highly  spoken 
of  by  Braxton  Hicks.  He  claims  in  this  way  to  deaden  the  reflex 
irritability  of  the  membrane. 

I  must  insist  on  this — that  opium  shall  be  used  in  such  cases  with 
great  care,  and  never  continued  long.  If  this  rule  is  neglected,  it 
will  lead  many  nervous  patients  to  contract  the  opium-habit,  which 
disease  is  worse  than  irritable  bladder. 

Debout  recommends  the  use  of  bromide  of  potassium  by  the 
mouth,  and  also  in  suppository,  combining  with  it  in  the  latter  tinct- 
ure of  opium  and  belladonna.  I  prefer  hydrobromic  acid  to  the 
bromide  of  potassium. 

When  the  trouble  is  due  to  masturbation,  moral  and  mental  in- 
fluences must  be  brought  to  bear,  as  well  as  medication  and  regula- 
tion of  diet  and  habits.  In  these  cases  the  bromides  will  be  of  serv- 
ice. 

If  all  otlier  treatment  fails  to  accomplish  the  desired  result,  resort 
should  be  had  to  mechanical  means,  viz.,  the  rapid  and  forcible  dila- 
tation of  the  urethra.  Some  authors,  indeed,  think  so  highly  of  this 
method  that  they  boldly  assert  that  time  spent  in  medication  is  time 
lost.  Astonishing  and  very  gratifying  results  have  certainly  followed 
its  use  in  a  number  of  cases.  Hewetson  reports  in  the  "Lancet" 
(page  4,  vol.  xii,  1875)  that  in  this  manner  he  cured  a  case  of  cysto- 
spasm  of  fifteen  years'  duration.  This  procedure  is  spoken  of  in  the 
highest  terms  by  Teale  ("  Lancet,"  page  27,  vol.  xi,  1875),  as  also  by 
Spiegleberg,  Tillaux,  and  others.  In  the  cases  where  this  treatment 
gives  relief,  I  believe  that  there  is  some  inflammatory  condition 
present,  or  at  least  something  more  than  a  neurosis. 

When  due  to  malaria,  the  treatment  is  usually  simple  and  satis- 
factory. Quinine  in  full  doses,  as  recommended  by  Bricheleau 
("  Arch.  gen.  de  med."),  for  one  day,  and  then  in  small  doses  before 
meals  for  a  week,  will  usually  cut  the  trouble  short,  and  j^revent  its 
return.  The  digestive  organs  require  attention  when  they  are  out 
of  order,  as  they  usually  are. 

If  due  to  hysteria,  the  original  disease  should  be  treated,  not, 
however,  neglecting  the  local  trouble.  When  accompanpug  acute 
or  chronic  systemic  diseases,  it  is  only  relieved  when  the  original 
disease  is  cured,  although  in  the  mean  time  the  annoyance  may  be 
greatly  alleviated  by  the  treatment  already  recommended. 


712  DISEASES  OF  WOMEN. 


nXUSTEATIVE    CASES    OF    FUlSrCTIONAL    DISEASES    OF    THE    BLADDEK,    EST 
WHICH    THERE    IS    NO    RECOGNIZABLE    ORGANIC   LESION. 

Neuralgia  of  the  TJretlira  and  Neck  of  the  Bladder. — A  married 
ladj,  who  had  never  been  pregnant,  was  tirst  seen  when  she  was 
twenty-six  years  of  age ;  she  had  then  been  three  years  married.  She 
was  well  developed,  and,  although  of  a  marked  nervous  tempera- 
ment, had  always  enjoyed  good  health.  From  puberty  onward  she 
had  suffered  pain  at  her  menstrual  periods,  but  not  of  severe  charac- 
ter. When  she  was  twenty-four  years  old  she  was  chilled  while  rid- 
ing a  long  distance  on  a  cold  day,  which  was  followed  by  frequent 
and  painful  urination.  This  was  somewhat  relieved  by  rest  and 
diuretics.  From  that  time  she  was  subject  to  violent  attacks  of  spas- 
modic pain  in  the  urethra  and  bladder.  The  pain  was  of  a  sharp, 
lancinating  character,  generally  coming  on  before  and  after  her  men- 
strual period ;  it  was,  however,  brought  on  at  any  time  by  nervous 
excitement  or  great  fatigue.  During  the  pain  there  was  some  diffi- 
culty in  urinating,  but  the  pain  was  neither  relieved  nor  increased 
by  the  act.  The  duration  of  the  pain  varied,  but  usually  did  not  last 
more  than  twenty-four  hours.  At  times  she  became  almost  frantic, 
so  great  was  the  suffering.  Large  doses  of  opium  would  relieve  her, 
but,  as  it  caused  very  distressing  after-effects,  she  avoided  taking  it, 
except  when  the  attacks  were  exceptionally  severe  and  prolonged. 
When  she  first  came  under  my  care  she  had  a  flexion  of  the  uterus, 
with  slight  general  tenderness  of  the  pelvic  organs,  which  accounted 
for  her  mild  dysmenorrhoea,  and  I  j)resumed  that  that  might  be  the 
cause  of  the  neuralgic  pains  in  the  bladder  and  urethra.  She  was 
treated  for  the  uterine  affection,  and  obtained  complete  relief  from 
the  painful  menstruation  and  tenderness  of  the  pelvic  organs  gener- 
ally, but  no  relief  was  obtained  from  the  periodic  attacks  of  pain 
in  the  urethra  and  bladder.  She  acknowledged  that  it  was  not  quite 
so  severe  at  her  menstrual  periods,  but  was  "  bad  enough  in  all  con- 
science," as  she  expressed  it. 

Careful  and  repeated  examinations  of  the  urine  were  made  M'hen 
she  had  pain,  and  when  she  was  free  from  it,  but  no  trace  of  any 
renal,  vesical,  or  urethral  disease  was  obtained.  The  urethra  and 
neck  of  the  bladder  were  examined  with  the  endoscope  several  times, 
but  were  found  to  be  normal.  Suspecting  that  the  neuralgic  pain — 
for  such  it  apparently  was — might  be  due  to  malaria,  she  was  given 
fifteen  grains  of  quinine  within  a  period  of  eight  hours,  followed 
by  Fowler's  solution  of  arsenic  in  doses  of  three  minims  after  each 
meal.     The  arsenic  treatment  was  continued  for  several  weeks,  and 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  713 

gave  lier  some  relief,  the  attacks  being  less  violent,  but  still  she 
suffered  greatly. 

Moderate  dilatation  of  the  urethra  was  then  practiced.  This  ag- 
gravated the  trouble.  Several  different  remedial  agents,  including 
opium,  hot  water,  aconite,  infusion  of  hops  and  belladonna,  were  in- 
jected into  the  bladder,  but  none  of  them  gave  any  relief.  The 
citrate  of  iron  and  quinia  in  five-grain-doses  was  then  prescribed  to 
be  taken  before  meals,  and  Parrish's  comjDOund  sirup  of  the  phos- 
phates in  drachm  doses  to  be  taken  after  meals.  When  the  pain 
came  on  she  w^as  directed  to  take  every  three  hours  a  drachm  of 
camphor- water  containing  eight  grains  of  muriate  of  ammonia,  and 
to  use  a  vaginal  douche  of  hot  water.  This  treatment  usually  re- 
sulted in  mitigating  the  pain,  but  did  not  completely  abolish  it. 
Thirty  minims  of  the  compound  spirits  of  ether  and  five  minims  of 
the  tincture  of  cannabis  Indica  every  four  bours  were  substituted  for 
the  camphor-water  and  muriate  of  ammonia  and  with  good  effect. 
Under  this  treatment  her  attacks  were  far  less  frequent,  and  the  re- 
hef  from  pain  was  prompt.  She  was  so  much  pleased  with  her  im- 
provement that  she  took  a  trip  through  the  West  and  returned 
quite  well,  and  has  remained  so  for  the  past  eight  years.  More  re- 
cently I  have  had  a  case  which  resembled  this  one  in  many  respects, 
particularly  as  regards  the  character  of  the  pain  and  its  causation, 
in  which  a  four-per-cent  solution  of  muriate  of  cocaine  instilled  into 
the  urethra  and  bladder  gave  relief. 

A  Peculiar  Form  of  Neuralgia  not  yet  described,  excited  by  a 
Desire  to  Pass  Water  and  by  Micturition.  (By  Dr.  Putegnat,  of 
Luneville.  (Gaz.  Hebdom  de  med.  et  chirurg.,  April  15,  1864.) — 
The  following  two  cases,  out  of  six  published  by  the  author,  will 
give  an  idea  of  this  peculiar  neuralgia,  which  consists  on  the  one 
hand,  in  a  special  sensation  in  the  bladder,  and  on  the  other,  in 
symptoms  of  a  neurosis  of  the  ulnar  nerve. 

M.  X.,  aged  fifty,  wdth  chestnut  hair,  of  a  nervous  and  san- 
guine temperament,  very  abstemious,  in  affluent  circumstances,  lead- 
ing a  very  active  hfe,  occupying  very  healthy  apartments,  free  from 
all  diathesis,  except  a  slight  rheumatic  affection,  liable  to  coryza  in 
cold,  damp  weather,  has  never  had  any  other  nervous  complaint  be- 
yond headache  and  occasional  gastralgia  after  eating  dressed  salads 
or  raw  fruit. 

From  time  to  time,  at  varying  intervals  of  weeks,  months,  and 
even  years,  without  any  apparent  physical  or  moral  cause,  in  all 
electric,  barometric,  and  thermometric  conditions  of  the  atmosphere, 
as  soon  as  his  bladder  is  full,  and  he  has  a  strong  desire  to  pass 


714  DISEASES  OF   WOMEN. 

water,  he  feels  along  the  urinary  passages,  especially  in  the  perinaeum 
a  peculiar  sensation  of  numbness,  not  very  painful,  but  acute,  burn- 
ing, lancinating,  and  unpleasant  from  the  accompanying  sense  of 
prostration.  This  strange  sensation  next  affects  the  shoulders, 
comes  down  both  arms,  along  the  course  of  the  ulnar  nerve  only, 
and  gives  rise  in  the  forearm,  the  little  and  the  ring  fingers,  to  the 
same  sensation  as  when  the  ulnar  nerve  is  strongly  compressed  at 
the  elbow.  The  pain  is  more  acute  on  the  left  than  on  the  right 
side,  lasts  about  twenty  or  thirty  seconds,  and  after  diminishing 
gradually,  disappears  without  leaving  any  trace  behind  it. 

M.  X.,  of  Luneville  ;  living  in  healthy  rooms ;  very  active, 
easily  moved  and  excited  ;  subject  to  headaches  and  to  rheumatic 
pains ;  free  from  any  diathesis ;  very  abstemious  ;  complains,  for 
several  successive  days,  but  at  irregular  intervals,  and  without  any 
known  cause,  of  a  strange  sensation  along  the  outer  border  of  the 
left  forearm,  on  the  inner  side  of  the  thumb,  and  the  outer  surface 
of  the  index-finger  especially.  This  sensation  he  compares  to  the 
one  produced  in  the  last  two  fingei's  of  the  hand  by  compression  of 
the  ulnar  nerve  at  the  elbow. 

The  painful  sensation  only  comes  on  whenever  he  has  a  strong 
desire  to  j^ass  water,  persists  during  micturition,  and  ceases  com- 
pletely immediately  afterward. 

On  analyzing  the  six  cases  of  the  author,  we  find  four  of  them 
to  have  occurred  in  females.  The  mean  age  of  the  patients  is  forty- 
six;  the  oldest  being  fifty-two,  and  the  youngest  thirty-six  years 
old.  They  are  all  in  easy  circumstances  ;  five  occupy  healthy  apart- 
ments, the  sixth  only  living  in  damp  rooms  on  the  ground  fioor. 
Three  patients  have  had  gastralgia ;  the  fourth  sciatica,  and  great 
troul)les  have  shaken  his  nervous  system ;  the  fifth  is  subject  to  vio- 
lent headaches ;  and  the  sixth,  a  female,  seems  to  have  epileptiform 
seizures,  and  has  a  double  neuralgia.  From  the  above,  then,  it  may 
be  concluded  that  neuralgia  and  great  nervous  excitability  are  pre- 
disposing causes  of  this  strange  neuralgic  affection. 

In  one  of  the  four  female  patients  the  catamenia  had  ceased  ;  in 
three  they  had  not,  and  in  two  of  those  thef  neuralgia  showed  itself 
before  and  during  the  menstrual  periods.  Uterine  congestion  seems 
then  to  be  a  predisposing  cause  also. 

Four  of  the  six  patients  had  had  rheumatic  pains  ;  but  the  other 
two  having  never  suffered  from  such  pains,  this  can  not  be  consid- 
ered as  the  exciting  cause  of  the  neuralgic  affection. 

The  desire  to  pass  water,  and  especially  the  act  of  micturition, 
brings  on  the  sensation,  which  only  appears  at  those  stated  times, 


FUNCTIONAL  DISEASES  OF   THE   BLADDER.  715 

and  it  reaches  its  maximum  intensity  at  the  beginning  of  the  mic- 
turition. It  has  all  the  characters  of  neuralgia,  and  can  even  aggra- 
vate, as  in  one  case,  an  already  pre-existing  neuralgia — that  of  the 
median  nerve. 

As  to  the  precise  seat  of  the  sensations,  we  find  them  affecting  the 
four  extremities  of  one  patient,  but  the  upper  limbs  only  of  the  re- 
maining five.  In  three  cases  they  simulate  to  perfection  neuralgia 
of  the  ulnar ;  and  in  two  they  are  felt  in  the  tips  of  all  the  fingers. 
In  one  case  they  coincide  with  and  intensify  pains  in  the  course  of 
the  median  ;  and  lastly,  as  in  the  first  case  we  have  given  above 
they  are  felt  in  the  distribution  of  the  left  radial  nerve. 

The  first  patient  complains  of  pain  in  both  shoulders,  especially 
the  left ;  the  fourth,  of  pain  in  both  arms  and  hands,  but  chiefiy  in 
both  breasts,  and  in  the  left  breast  more  than  the  right ;  the  sixth, 
again,  of  pain  in  both  forearms  and  hands,  but  more  marked  on  the 
left  side.  Hence,  the  left  side  of  the  body  would  seem  to  be  either 
the  only  one  affected,  or  the  one  most  affected. 

The  patients  always  distinguished  clearly  the  special  painful  sen- 
sations felt  in  the  urinary  passages  from  the  normal  sensations  due 
to  a  distention  of  the  bladder  and  the  subsequent  desire  to  pass 
water. 

Retention  of  Urine  Due  to  Hysteria. — A  single  lady,  thirty -one 
years  of  age,  of  delicate  organization  and  pronounced  nervous  tem- 
perament, yet  very  quiet  and  self  possessed  in  manner,  suffered  for 
some  time  with  difficulty  of  urination.  At  times  she  could  m'inate 
very  well,  at  others  she  was  obliged  to  try  repeatedly  before  she 
succeeded.  She  was  a  lady  of  high  culture  and  liberal  education, 
but  was  not  interestedly  occupied,  and  hence  she  had  much  time  for 
introspection. 

She  called  her  physician  who  prescribed  remedies,  but  finding 
that  they  did  not  give  her  relief,  made  an  examination  of  the  pelvic 
organs  but  could  find  no  cause  for  her  inability  to  urinate  with  facil- 
ity. 

Soon  after  she  was  taken  with  complete  retention  which  was  re- 
lieved by  the  catheter.  This  continued  for  weeks,  requiring  the 
doctor  to  visit  her  three  times  a  day,  and  occasionally  at  night,  to 
pass  the  catheter.  For  some  reason  which  was  not  very  evident 
and  could  hardly  be  due  to  weakness  or  suffering,  she  remained  in 
bed  most  of  the  period  during  which  the  catheter  was  used.  Be- 
coming weary  of  such  close  attention,  the  doctor  tried  letting  her 
wait,  to  see  if  a  full  distention  of  the  bladder  would  have  any  good 
effect.     This  caused  her  so  much  pain  that  the  doctor  felt  somewhat 


716  DISEASES  OP  WOMEN. 

mortified  at  liis  want  of  feeling  in  permitting  her  to  suffer.  Dur- 
ing this  time  he  had  tried  a  number  of  remedies,  but  without 
eiieet.  At  this  stage  of  the  history  I  was  called  in  consultation  ; 
I  could  find  no  evidence  of  any  organic  disease,  local  or  general. 
The  urine  was  found  upon  examination  to  be  normal.  I  suggested 
to  the  attending  physician  that  the  trouble  was  hysteria,  but  he  as- 
sured me  that  she  was  sin^ilarly  free  from  all  evidences  of  that 
affection.  Indeed,  he  had  found  her  a  remarkably  calm  and  sensible 
lady,  and  very  free  from  nervousness  of  every  kind.  The  impression 
that  I  received  was  that  there  was  a  very  decided  hysterical  element 
in  the  case,  and  I  advised  full  doses  of  bromide  of  potassium  and  a 
sitz-bath  when  she  desired  to  urinate.  I  also  recommended  that  she 
should  go  to  Saratoga,  and  drink  Hathorn  water.  She  did  this, 
and  the  water  gave  her  diarrhoea,  and  her  retention  was  immedi- 
ately relieved. 

Frequent  Urination  Due  to  Hysteria. — A  lady  twenty-three  years 
of  age,  in  very  good  general  health,  and  living  in  very  easy  circum- 
stances, had  some  disappointment  which  caused  her  much  distress. 
She  had  faintings  of  a  mild  character  which  alarmed  her  mother 
and  called  forth  much  sympathy.  About  this  time  she  began  to 
suffer  from  frequent  urination.  This  did  not  yield  to  the  treatment 
employed  by  the  family  physician,  and  she  was  brought  to  my  office 
for  advice.  Her  health  was  at  times  excellent,  but  she  was  greatly 
annoyed  by  this  frequent  urination.  The  urine  was  normal  except 
at  times  when  it  was  of  a  very  light  color.  She  could  sleep  all  night 
without  being  disturbed  by  a  desire  to  urinate.  If  by  chance  she 
did  not  go  to  sleep  immediately  on  retiring  she  was  obliged  to  urin- 
ate every  few  minutes,  and  if  she  was  awakened  in  the  night  she 
had  to  urinate  many  times  before  she  could  sleep  again. 

Any  little  mental  excitement,  such  as  going  to  church  or  to  the 
theatre,  would  bi-ing  on  the  trouble,  so  that  she  had  to  give  up  all 
public  duties  and  pleasures.  Systematic  exercise  and  occupation, 
cold  baths,  bromide  of  sodium,  and  a  full  assurance  on  my  part  that 
she  would  soon  recover,  helped  her  greatly.  She  was  commanded 
in  a  very  decided  way  to  resist  the  inclination  to  such  frequent  urin- 
ation, and  she  obeyed  orders. 

Soon  after  this  her  attention  was  attracted  in  another  and  more 
interesting  direction,  and  she  roeovcred  completely. 

Frequent  Urination  from  Perverted  Sexual  Function, — A  girl 
nineteen  years  of  age  who  had  a  good  general  organization  and  en- 
joyed good  health  up  to  puberty  at  fourteen,  sought  advice  regard- 
ing impatience  of  her  bladder.     She  was  obliged  to  return  home 


FUNCTIONAL   DISEASES   OF   THE   BLADDER.  717 

from  boarding-school  because  slie  had  to  urinate  so  often  that  she 
could  not  attend  to  her  studies  and  recitations.  Her  general  nutri- 
tion was  good,  she  menstruated  regularly,  freely,  and  without  acute 
pain.  Her  nervous  system  was  depressed.  She  was  sometimes  lan- 
guid, low  spirited  and  fretful,  at  other  times  she  was  bright  and  dis- 
posed to  be  cheerful.  Her  manner  was  rather  timid  and  excited. 
Her  hands  were  clammy,  and  her  eyes  dull,  and  had  dark  streaks 
under  them.  Her  chief  symptom  was  the  frequent  urination  which 
persisted  but  was  much  worse  at  times  than  at  others.  Occa- 
sionally she  would  pass  the  night  without  getting  up  more  than 
once  or  twice,  but  during  the  day  she  was  often  obliged  to  urinate 
every  half-hour.  There  was  very  little  pain  except  occasionally  a 
little  smarting  at  the  meatus.  She  complained  of  heat  and  burning 
about  the  vulva  and  occasional  aching  in  the  region  of  the  ovaries. 
She  was  easily  fatigued  and  had  backache,  especially  on  standing  and 
walking — leucorrhoea  troubled  her  only  at  times. 

I  suspected  at  first  that  she  had  either  cystic  and  urethral  con- 
gestion, or  else  hysteria  giving  rise  to  excessive  renal  secretion  of 
limpid  urine,  but  an  examination  of  the  quantity  and  composition  of 
the  urine  proved  the  contrary.  She  was  put  in  charge  of  a  very 
competent  nurse  who  was  directed  to  find  out  the  habits  of  the 
patient. 

The  report  of  the  attendant  was  that  she  had  begun  to  indulge  in 
masturbation  soon  after  puberty,  and  that  the  habit  had  gradually 
grown  upon  her.  Her  nurse  surprised  her  by  telHng  her  the  cause 
of  her  suffering,  and  readily  gained  her  consent  to  make  all  due 
efiPorts  to  recover  her  self-control.  By  care,  occupation,  and  exercise 
out-of-doors,  and  the  moral  control  of  her  nurse,  she  began  to  im- 
prove. Bromide  of  sodium  was  given  when  she  was  very  restless 
and  irritable,  but  no  other  medication,  except  the  free  use  of 
bathing. 

In  about  two  months  the  frequent  urination  had  disappeared,  al- 
though she  would  occasionally  have  a  day  or  a  night  when  she  suf- 
fered in  that  way  a  little.  She  now  has  two  children,  and  enjoys 
life  very  well,  being  free  from  her  former  symptoms  and  no  doubt 
cured  of  her  former  habit. 

Frequent  and  DifB-cult  Urination  from  Sexual  Continence. — The 
patient,  a  strong  and  active  lady  in  good  circumstances,  was  married 
at  twenty-one  years  of  age,  and  had  her  first  baby  before  she  was 
twenty-two.  She  nursed  the  child  for  eighteen  months.  Her 
menses  came  on  when  the  child  was  one  year  old.  About  three 
years  after  her  marriage,  her  husband,  a  strong,  vigorous  man,  died 


Y18  DISEASES  OF   WOMEN. 

of  pneumonia.  Several  months  after  the  loss  of  her  husband  she 
began  to  suffer  at  times  from  frequent  urination,  and  also  had  some 
difficulty  in  voiding  the  urine,  requiring  voluntary  efforts.  These 
attacks  would  pass  off,  and  she  would  be  comfortable  for  days, 
when  the  same  irritation  of  the  bladder  would  return.  She  was 
always  made  worse  by  excitement,  often  being  kept  awake  nearly 
all  night  after  spending  the  evening  in  company. 

Her  symptoms  became  so  troublesome  that  she  sought  advice  of 
a  physician,  who  treated  her  for  cystitis  by  giving  medicines  of  va- 
rious kinds.  When  she  first  came  under  my  observation  I  found 
her  in  perfect  health  in  every  way.  The  urine  was  normal,  and 
caused  no  pain  when  she  passed  it.  I  was  easily  able  to  exclude  all 
diseases  except  deranged  innervation  from  a  possible  malarial  influ- 
ence. The  periodical  character  of  the  attacks  favored  this  view  of 
the  case,  but  the  use  of  the  anti-malarial  remedies  gave  no  relief.  I 
then  ordered  her  to  take  more  active  exercise  and  a  limited  quantity 
of  plain  food,  to  bathe  frequently,  and  to  avoid  excitement  as 
far  as  possible.  Bromide  of  sodium  was  also  given  when  her 
suffering  was  most  severe.  She  improved  on  this  treatment  for  a 
time,  in  fact  she  became  so  much  better  that  I  lost  sight  of  her  for 
nearly  a  year.  She  returned  to  say  that  her  former  symptoms  had 
returned,  and  were  about  as  troublesome  as  before.  The  same  treat- 
ment was  employed  but  did  not  help  her  very  much.  She  was 
now  rather  nervous  and  restless,  and  disposed  to  be  emotional. 

Three  months  afterward  she  was  married,  and  left  the  city  on 
an  extended  wedding-tour.  Upon  her  return  she  reported  herself 
as  perfectly  w^ell. 

A  Case  of  Malarial  Irritation  of  the  Bladder  in  the  Female.  (By 
Henry  K.  Leake,  M.  D.,  Dallas,  Texas.  Abstract  of  a  paper  read 
before  the  Texas  State  Medical  Association.)  I  desire  to  record 
an  observation,  which  I  have  recently  made,  exemplifying  the 
effect  that  tlie  malarial  poison  may  exert  upon  the  female  blad- 
der ;  an  observation  which  may  appear  commonplace  since,  as  is 
well  known,  it  has  not  escaped  mention  by  Prof.  Skene  in  his  excel- 
lent work  on  tlie  "  Diseases  of  the  Bladder  and  Urethra  in  the 
Female"  as  well  as  by  other  authors  of  equal  or  less  prominence, 
who  have  attended  to  the  same  subject. 

Nevertheless,  considering  the  mere  allusions  by  these  writers  to 
irritation  of  the  bladder  in  women,  which  may  be  caused  by  the 
presence  of  malaria  in  the  system,  on  account,  doubtless,  of  the  rare 
occurrence  of  this  affection,  it  may  be  (juestioned  whether  the  latter 
has  been  sufficiently   individualized  as  a  distinct  and  independent 


FUNCTIONAL  DISEASES  OP   THE  BLADDER.  YlQ 

malady,  deserving  especial  prominence  in  the  nosology  of  diseases  of 
the  bladder,  which  seriously  disturb  the  functions  of  this  sensitive 
viscus.  There  is  the  additional  reason,  also,  for  reporting  the  ex- 
perience which  I  have  had  of  this  peculiar  and  interesting  disorder, 
in  the  fact  that  much  obscurity  yet  surrounds  the  entire  subject  of 
disturbance  of  the  functions  of  this  organ  in  the  female,  the  integrity 
of  which  is  so  vital  to  the  comfort,  happiness,  and  safety  of  the  in- 
dividual. 

Moreover,  such  conditions  often  tax  the  diagnostic  acumen  of 
the  physician  to  the  utmost,  and  even  when  by  the  exclusive  method, 
rigorously  employed,  many  causes  of  UTitation  of  the  bladder  may 
be  eliminated  from  the  problem  in  hand,  there  will  yet  remain  in 
particular  cases,  other  causes  which  may  elude  discovery,  thus  ob- 
scuring the  pathogeny  and  defeating  every  measure  of  treatment 
which  is  attempted. 

About  March  1st,  of  the  present  year,  a  lady,  whose  health  has 
been  uninterruptedly  good,  thirty-seven  years  of  age,  the  mother  of 
six  children,  the  last  of  which  being  an  infant  of  four  months,  ap- 
plied to  me  for  treatment  for  what  she  considered  the  ailment  to 
be,  incontinence  of  urine.  She  stated  that  the  condition  had  come 
on  gradually,  at  the  first  amounting  to  a  mere  frequency  of  urina- 
tion during  the  day,  vfithout  any  attendant  pain  or  other  symptom 
which  attracted  her  attention.  This  frequency  had  increased,  how- 
ever, to  such  an  extent  as  to  seriously  embarrass  her  in  the  perform- 
ance of  domestic  duties,  and  prevent  her  from  visiting  friends,  or 
doing  necessary  shopping.  Moreover,  she  soon  became  troubled  at 
night,  often  rising  six  or,  perhaps,  a  dozen  times,  in  obedience  to 
the  urgent  calls  for  micturition.  The  amount  of  urine  passed  at 
each  discharge  was  not  large,  but  exceeded  in  quantity  that  ordi- 
narily retained  in  cases  of  acute  cystitis,  which  the  affection  in 
many  respects  closely  resembled. 

There  were  no  deposits  in  the  urine  worth  noting.  It  appeared 
to  be  somewhat  higher  colored  than  normal.  There  was  also  a 
superabundance  of  mucus,  in  the  form  of  large  floccuH,  but  no  pus 
or  blood. 

As  the  case  progressed,  the  desire  to  evacute  the  bladder  was 
preceded  by  a  sharp  twinge  of  pain,  which  the  patient  aveiTed  was 
"  low  down  at  the  very  neck  of  the  bladder,"  but  which  was  imme- 
diately relieved  on  emptying  the  viscus.  There  was  no  tenderness 
at  any  point  except  a  slight  pain  experienced  when  the  neck  of  the 
bladder  was  firmly  pressed  toward  the  pelvis. 

The  frequency  of  micturition  increased  to  almost  constant  drib- 


720  DISEASES  OF  WOMEN. 

bling  from  the  bladder,  botli  daily  and  nocturnally  the  cloud  of 
mucus  in  the  urine  was  much  augmented,  and  while  the  color  a]>- 
peared  to  remain  unchanged,  there  was  evidently  a  large  excretion  of 
solid  matter  composed  probably  of  phosphates. 

The  uneasiness  elicited  at  the  neck  of  the  bladder  by  pressure  on 
this  part  soon  changed  to  actual  soreness.  At  the  end  of  the  second 
week  the  case  had  passed  into  one  of  apparently  serious  import,  and 
was  operating  with  telling  effect  on  the  vitality  and  mental  equipoise 
of  the  patient. 

The  tripod  of  treatment,  namely,  rest,  opium,  and  alkalies,  upon 
which  Yan  Buren  and  Keyes  cogently  jirotest  the  successful  manage- 
ment of  cystitis  rest,  was  relied  on  to  relieve  what  I  now  feared 
was  a  case  of  this  distressing  disease,  the  cause  of  which  I  could 
not  then  determine.  The  constitutional  effect  of  belladonna  was 
evoked  also  to  mitigate  the  symj^toms,  and  finally  hot-water  vaginal 
injections  were  employed  for  their  well-known  analgesic  and  anti- 
phlogistic effects  upon  the  pelvic  viscera. 

Such  measures  gave  only  temporary  relief,  the  features  of  the 
case  resuming  their  original  character  whenever  the  effect  of  medi- 
cation—which was  occasionally  suspended  to  ascertain  the  status  quo 
of  the  disease — had  passed  off. 

At  the  beginning  of  the  third  week  from  the  first  appearance  of 
the  symptoms,  the  patient  complained  of  slight  chilliness  toward 
evening,  and  it  was  obsei-ved  that  this  was  followed  by  fever,  the 
thermometer  in  tlie  mouth  registering  101.°  These  symptoms  were 
interpreted  to  indicate  the  constitutional  expression  of  the  local  in- 
fiammation  existing  in  the  bladder.  Hence,  no  special  attention  was 
directed  toward  them.  The  chilliness  was  repeated,  however,  on  the 
third  evening,  and  on  the  fourth  day  at  the  same  hour  reap]5eared 
as  the  prodrome  of  a  marked  rigor,  followed  by  an  abrupt  rise  of 
temperature  of  103°  succeeded  by  sweating  and  a  return  to  the 
normal  temperature  m  about  four  hours,  thus  clearly  demonstrating 
a  well-defined  periodicity  of  the  febrile  movement. 

Suspicion  being  now  aroused  as  to  the  essential  nature  of  the 
case,  the  patient  was  promptly  placed  on  ten-grain  doses  of  the  sul- 
phate of  quinine,  to  be  taken  every  four  hours  with  mercurial  and 
saline  purgatives,  the  latter  being  indicated  by  the  appearance  of  the 
tongue  and  the  confined  state  of  the  bowels,  which  was  due  not  alto- 
gether to  the  opium  administered,  since  this  physical  n;odifier  had 
been  exhibited  both  freely  and  sinmltaneously. 

The  substitution  of  the  quinine  for  the  treatment  previously 
pursued,  like  the  fabled  wand  of  the  magician,  broke  tiie  spell  ol 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  ^91 

enchantment,  which,  by  its  subtle  and  potent  influence  had  held 
the  patient  with  relentless  grasp  for  three  weeks  and  had  trans- 
formed a  hopeful  and  contented  disposition  into  one  of  melancholy 
and  apprehension. 

At  the  end  of  four  days  from  the  administration  of  the  first 
dose  of  quinine  the  patient  was  virtually  convalescent.  During  this 
period  no  opiate  was  employed  nor  any  other  medicine  but  quinine 
taken,  save  an  occasional  dose  of  neutral  mixture,  chiefly  for  its  su- 
dorific effect.  Nevertheless  the  irritation  of  the  bladder  did  not  re- 
turn, and  the  close  of  the  week  found  the  patient,  although  debili- 
tated by  the  trying  ordeal  through  which  she  had  passed,  enabled 
to  resume  her  accustomed  duties. 

Periodical  Attacks  of  Frequent  and  Painful  Urination  and  Vesical 
Tenesmus  caused  by  Malaria. — About  two  years  ago  a  patient  came  to 
my  college  clinic  complaining  as  follows  :  In  the  afternoon  of  each 
day  she  experienced  a  sense  of  heat  and  burning  in  the  bladder  and 
urethra,  with  a  frequent  and  irresistible  desire  to  urinate.  Evacua- 
tion of  the  bladder,  attended  with  a  great  deal  of  smarting  and  pain 
in  the  urethra,  did  not  give  complete  relief  but  left  some  vesical 
tenesmus  which  increased  in  severity  as  the  bladder  became  dis- 
tended. These  symptoms  persisted  during  the  night  and  kept  her 
awake,  but  toward  morning  her  suiferings  entirely  left  her,  and  she 
became  quite  comfortable  until  the  next  afternoon.  This  condition 
had  existed  for  nearly  two  months,  and  accordingly  her  digestion  be- 
came impaired  and  her  strength  diminished.  This  was  attributed 
by  her  to  the  want  of  sleep,  and  no  doubt  in  part  was  due  to  this 
cause.  The  urine  was  examined,  and  found  to  be  normal  except  that 
it  contained  a  slight  excess  of  phosphates.  She  was  carefully  exam- 
ined, and  no  evidence  of  organic  disease  was  found.  While  she  al- 
ways enjoyed  full  health  and  had  been  a  vigorous  woman,  she  had  had 
an  attack  of  malarial  fever  about  six  months  before  I  saw  her,  and 
about  the  time  this  bladder  trouble  came  on  she  said  she  had  symp- 
toms of  her  former  ague.  From  the  facts  in  her  history  I  ventured 
to  state  to  my  class  that  this  was  a  functional  derangement  of  the 
bladder  and  urethra  caused  by  malaria,  which  would  promptly  yield 
to  judicious  doses  of  quinine.  I  accordingly  prescribed  twenty 
grains  of  quinine  to  be  taken  between  early  morning  and  noon,  to 
be  followed  by  two-grain  doses  before  meals  with  four  drops  of 
Fowler's  solution  of  arsenic  after  meals.  She  was  ordered  to  report 
at  the  clinic  the  following  week.  She  did  so,  and  declared  that  she 
had  been  perfectly  well  since  the  first  day  she  took  the  medicine. 
The  quinine  and  arsenic  in  small  doses  were  continued  for  three 
47 


722  DISEASES  OF  WOMEN. 

weeks,  at  the  end  of  which  time  she  reported  herseK  as  having  been 
well  and  free  from  all  irritation  of  the  urinary  organs. 

No  change  in  the  character  of  the  nrine  could  have  occurred  to 
produce  such  marked  periodicity  in  tlie  functional  derangement  of 
the  bladder  and  urethra ;  moreover,  the  urine  was  found  to  be  nor- 
mal, and  she  completely  recovered  on  the  use  of  quinine. 

Vesical  Tenesmus  and  Frequent  Urination  due  to  Prolapsus  and  In- 
flammation of  the  Ovaries.— In  prolapsus  of  the  ovaries  and  inflamma- 
tory alfections  of  these  organs  irritation  of  the  bladder  often  occurs. 
This  is  illustrated  by  the  following  case : 

A  young  girl  of  twenty-one  was  brought  to  me  suffering  from 
great  distress  in  the  pelvis,  which  was  much  aggravated  by  standing 
or  walking.  Her  suffering  was  constant,  but  was  tolerable  when  she 
remained  in  the  recumbent  position.  She  began  to  complain  about 
six  months  before  I  saw  her,  and  about  the  same  time  she  found 
that  she  was  obliged  to  urinate  too  often,  and  that  there  was  an  un- 
easy feeling  in  the  bladder  most  of  the  time,  a  feeling  as  if  the 
bladder  had  not  been  fully  evacuated. 

She  was  nmch  worse  at  her  menstrual  periods.  Upon  a  thor- 
ough examination  I  found  both  ovaries  prolapsed,  slightly  enlarged, 
and  exceeding  tender.  In  every  other  respect  she  was  perfectly 
well.  In  consultation  with  her  physician,  a  course  of  treatment  for 
the  ovarian  disease  was  decided  upon.  This  was  fully  and  faithfully 
tried  for  over  one  year,  but  at  the  end  of  that  time  she  was  worse. 

She  was  then  quite  impatient,  being  very  nervous  and  irritable 
from  her  confinement  and  suffering.  Her  parents  and  friends  were 
quite  weary  of  seeing  her  suffer.  Her  bladder  ii-ritation  was  no 
better ;  in  fact  it  was  a  great  source  of  suffering.  She  could  not 
urinate  without  getting  up,  and  the  erect  position  increased  her 
ovarian  pain.  The  ovaries  were  still  prola2)sed  and  just  as  tender, 
in  fact,  more  so  than  they  had  been. 

The  complete  failure  of  treatment  so  far  indicated  that  removal 
of  the  ovaries  was  the  only  thing  that  promised  to  give  her  relief. 
Accordingly  the  ovaries  were  removed,  and  she  made  a  rapid  recov- 
ery from  the  operation  and  was  completely  relieved  not  only  from 
her  ovarian  pain  but  also  from  the  frequent  urination  and  vesical 
tenesmus. 

It  should  be  stated  that  at  no  time  was  there  any  evidence  cf 
cystitis  found  upon  frequent  and  careful  examinations. 


CHAPTER   XL. 

FUNCTIONAL   DISEASES    OF    THE    BLADDEK  (cONTINTJED). 

Having  considered  the  vesical  derangements  in  which  there  is 
no  recognizable  organic  lesion,  and  which  may  be  local  neuroses,  or 
may  be  due  to  hysteria,  disorder  of  the  sexual  function,  malarial  or 
ovarian  affections,  I  will  now  invite  attention  to  the  second  class  of 
these  disorders. 

I.  Derangements  of  function  due  to  diseases  of  the  nutritive  and 
nervous  systems,  or  to  abnormal  conditions  of  the  urine  which  re- 
sult therefrom. 

This  class  naturally  subdivides  itself  into  : 

1.  Derangements  occurring  in  both  acute  and  chronic  diseases. 

2.  Derangements  due  to  consequent  abnormal  conditions  of  the 
urine. 

1.  Of  the  derangements  which  occur  in  the  course  of  acute  dis- 
eases, such  as  retention  and  incontinence  of  urine  and  frequent  urin- 
ation, nothing  more  than  the  mere  mention  is  necessary.  Tliey 
rarely  require  any  treatment,  except  possibly  in  the  case  of  reten- 
tion, when  catheterization  is  to  be  employed,  and  they  cease  as  soon 
as  the  acute  stage  is  passed.  Those,  however,  which  are  due  to 
chronic  affections  of  the  nutritive  and  nervous  systems  are  more 
permanent,  and  often  tax  the  resources  of  the  physician  to  the 
utmost.     The  two  most  important  are  : 

(a)  Paralysis  of  the  bladder,  and, 

{h)  Incontinence  of  urine. 

(a)  Paralysis  of  the  Bladder. — This  affection  has  also  been  de- 
scribed under  the  names  of  weakness  or  palsy  of  the  bladder,  and 
vesical  atony.  It  occurs  in  two  forms :  First,  from  causes  residing 
in  the  organ  itself ;  second,  from  those  due  to  outside  influences. 
As  affections  in  the  first  form  ^vill  be  fully  described  in  another 
place  I  shall  here  simply  mention  them.  They  are :  Fatty  degenera- 
tion and  atrophy  of  the  muscular  walls  of  the  bladder,  a  common 

723 


724  DISEASES  OF  WOMEN. 

cause  of  paralysis  of  this  \ascus  in  old  women ;  overstrain  of  tlie 
muscular  structure  from  prolonged  retention,  voluntary  or  involun- 
tary ;  displacements  and  inflammations  of  neighboring  organs  aifect- 
ing  its  position  or  nutrition ;  and  abdominal  and  pelvic  tumors. 

In  fevers  of  a  serious  type  the  power  of  nerve  conduction  may 
be  either  lost  or  impaired,  and  a  partial  or  total  vesical  paralysis  re- 
sult, with  overdistention  and  dribbhng  of  urine. 

The  second  form  is  due  to  influences  acting  from  without  the 
bladder,  and  includes  acute  and  cln-on'ic  meningitis ;  apoplexies  of 
the  brain  or  spinal  cord ;  sopor ;  delirium  ;  myelitis  of  the  lower 
part  of  the  spinal  cord  ;  inflammation  of  any  kind  primarily  affect- 
ing or  involving  in  its  results  either  the  lumbar  nerves  or  ganglia ; 
endarteritis  deformans  of  the  pelvic  arteries  ;  lumbar  or  renal  ab- 
scesses ;  blows  or  fall  upon  the  loins,  supra-pubic  region,  or  head ; 
shock  or  disease  of  the  vesical  or  lumbar  nerves  from  the  prolonged 
use  of  opium  or  poisoning  by  it,  and  also  shock  due  to  overdisten- 
tion of  the  organ  itself. 

Syrrqytomatology. — Except  in  cases  of  injury  of  the  brain  and 
apoplexies,  the  invasion  of  the  disease  is  usually  very  gradual.  This 
is  especially  the  case  in  the  aged,  and  sometimes,  though  rarely,  in 
young  peoj^le.  The  patient  first  observes  that  the  urine  is  expelled 
from  the  bladder  with  less  force  than  usual ;  that  the  act  of  empty- 
ing the  bladder  is  more  slowly  accomplished,  and  that  after  a  time 
the  organ  is  unable  to  expel  its  contents  without  considerable  strain- 
ing and  aid  from  the  abdominal  muscles.  At  a  later  date,  if  the 
disease  goes  on  unchecked,  the  stream  is  less  and  less  forcibly  ejected, 
intermits,  and  the  bladder,  after  much  straining,  is  but  pai-tially 
emptied.     Finally,  partial  or  complete  retention  follows. 

The  female  bladder  seems  to  be  capable  of  more  distention  than 
that  of  the  male.  Lieven,  in  a  case  of  supposed  ovarian  tumor,  re- 
moved by  catheterization  about  nine  pints  of  urine.  The  patient  was 
a  woman  thirty-three  years  of  age.  The  fundus  of  the  bladder 
reached  as  high  as  the  ensiform  cartilage.  I  once  saw  a  case  exactly 
like  this,  except  that  the  bladder  only  reached  to  about  two  inches 
above  the  umbilicus.  More  than  a  gallon  has  been  drawn  off  by 
Hof  meier  and  others. 

A  peculiarly  interesting  experiment  bearing  upon  the  dilatability 
of  the  bladder  was  made  by  Budge.  He  found  that  section  of  the 
lower  part  of  the  spinal  cord,  when  the  bladder  was  considerably 
distended,  allowed  increased  reflex  action  of  the  sphincter,  and 
enormous  distention  then  took  place — even  more  than  could  be  pro- 
duced by  force,  after  death.     This  is  especially  interesting  in  rela- 


FUNCTIONAL  DISEASES  OF  THE   BLADDER.  Y25 

tion  to  vesical  paralysis  and  retention  due  to  injury  or  disease  of  the 
lumbar  portion  of  the  spinal  cord. 

In  some  cases  of  overdistention  the  resistance  of  the  sphincter  is 
overcome  somewhat,  and  a  constant  dribbling  of  urine  takes  place. 
It  has  been  called  by  some  authors  incontinentia  parodoxa.  These 
cases  are  hable  to  be  mistaken  for  those  of  pure  incontinence. 

In  rare  cases  rupture  of  the  bladder  may  take  place  ;  more  com- 
monly dilatation  of  the  ureters  and  hydronephrosis.  If  the  condi- 
tion of  vesical  distention  be  not  soon  relieved,  vesical  catarrh,  true 
inflammation,  ulceration,  and  death  take  place.  In  cases  due  to  in- 
jm*y  or  disease  of  the  spinal  cord,  low  down,  there  seems  to  be  a 
paralysis  or  peculiar  condition  of  the  nerves  presiding  over  the  nu- 
trition of  the  vesical  mucous  membrane,  and  destructive  changes  are 
not  uncommon. 

Diagnosis. — The  diagnosis  though  easy,  is  sometimes  not  made, 
owing  to  careless  observation  or  ignorance.  When  called  to  a  case 
where  there  is  supposed  distention  of  the  bladder,  the  abdomen 
should  first  be  examined  to  see  if  there  are  signs  of  a  tumor,  and 
then  a  catheter  should  be  passed  if  that  be  possible,  to  determine 
whether  an  abnormal  amount  of  urine  is  present.  K  this  is  the 
case,  and  the  tumor  gradually  subsides  as  the  urine  flows,  the  diag- 
nosis is  at  once  made.  "When,  however,  a  catheter  can  not  be  passed 
into  the  viscus,  fluctuation  should  be  sought  both  through  the  vagina 
and  on  the  surface  of  the  tumor.  If  the  diagnosis  be  still  obscure, 
the  aspirator-needle  should  be  passed  into  the  tumor,  and  its  fluid 
contents  carefully  tested.  The  age  of  the  patient,  the  duration  of 
the  disease,  and  its  time  and  method  of  invasion  will  aid  in  settling 
the  question.  The  trouble  may,  however,  occur  at  almost  any  age, 
and  the  fact  that  a  little  urine  has  been  passed  at  short  intervals 
will  tend  to  deceive. 

In  the  early  stages  of  the  disease  an  idea  can  be  gained  as  to  its 
progress  by  carefully  noting  the  amount  of  urine  passed  at  each 
micturition,  the  amount  passed  in  twenty-fom*  hours,  the  length  of 
intervals  between  urination,  the  force  of  the  stream,  whether  the 
bladder  is  fully  or  but  partially  emptied,  and  whether  the  stream 
intermits.  The  urine  should  be  examined  often,  else  cystitis  may 
get  a  firm  foothold  before  its  existence  is  recognized.  In  drawing 
off  the  urine  for  testing  or  other  purposes,  the  catheter  should  be 
absolutely  clean. 

Incontinentia  paradoxa  must  be  differentiated  from  incontinence 
due  to  mechanical  causes,  such  as  abnormal  urine,  or  the  pressure  of 
neighboring  organs  upon  the  bladder. 


726  DISEASES  OF  WOMEN. 

Prognosis. — If  the  disease  be  uncomplicated  the  prognosis  is 
good.  Paralysis  of  the  organ  accompanying  the  fevers,  dysentery, 
peritonitis,  and  the  like,  usually  disappears  mth  the  cure  of  the 
original  disease. 

If  the  paralysis  be  accompanied  by  disease  of  the  bladder-walls, 
or  if  it  occurs  in  weak,  debilitated  constitutions,  or  has  been  of  long 
duration,  or  occurs  in  old  age,  the  prognosis  is  not  good.  A  cure, 
if  effected  at  all,  will  be  only  after  long  and  tedious  treatment. 

When  due  to  centric  causes  or  to  serious  spinal  disease  or  injury, 
or  when  it  occurs  in  old  people,  or  with  meningitis,  or  with  sys- 
temic trouble,  the  prognosis  is  very  grave  indeed. 

Causation. — Deranged  innervation  due  to  the  central  lesion 
already  mentioned,  either  cerebral  or  spinal,  may  be  regarded  as 
the  principal  cause  of  this  affection.  If  the  paralysis  has  been  of 
long  duration  nutritive  changes  may  occur  in  the  bladder,  but  as 
these  will  be  discussed  under  the  appropriate  head  I  need  say  noth- 
ing of  them  here. 

Treatment. — In  all  cases  where  there  is  fear  of  vesical  distention, 
the  bladder  should  be  emptied  at  stated  intervals.  By  way  of 
helping  the  patient  to  pass  water  herself,  hot  hip-baths  may  be  tried 
and  fomentations  over  the  bladder.  The  sound  of  water  falling 
from  one  vessel  into  another  often  accomplishes  the  same  result.  If 
these  means  do  not  succeed  the  catheter  must  be  used. 

And  here  attention  may  be  called  to  a  very  important  practical 
point  in  connection  with  the  use  of  the  catheter.  When  the  blad- 
der has  become  very  much  distended  it  can  not  be  thoroughly  emp- 
tied unless  pressure  is  made  upon  the  abdominal  walls  ;  if  this  press- 
ure is  made  while  the  catheter  is  in  the  bladder,  and  then  discontin- 
ued, air  will  be  drawn  through  the  catheter  into  the  bladder  and 
decomposition  of  the  urine  will  thus  be  favored. 

Marked  distention  can  usually  be  relieved  by  the  catheter.  In 
some  cases,  however,  the  bladder  rises  up  into  the  abdomen  and 
puts  the  urethra  upon  the  stretch,  thus  changing  the  direction  of  its 
axis  from  the  normal  to  one  from  below  directly  upward,  the  canal 
being  nearly  parallel  to  the  posterior  surface  of  the  pubic  symphy- 
sis. In  these  cases  passing  the  catheter  will  tax  the  skill  somewhat. 
Great  care  must  be  used  to  avoid  injuring  the  urethra. 

In  emptying  a  greatly  distended  bladder  a  binder  should  be  ap- 
plied to  the  abdomen  and  tightened  gradually  as  the  urine  flows.  It 
is  not  safe  to  draw  off  all  the  urine  at  once.  It  is  better  to  take 
away  about  half,  and  then  after  a  time  to  draw  off  more,  until  the 
organ  is  empty.     Syncope  and  even  death,  which  is  said  to  have 


FUNCTIONAL  DISEASES   OF  THE   BLADDER.  727 

occurred  in  these  cases  after  rapid  emptying  of  the  organ,  are  prol> 
ably  due  to  the  sudden  removal  of  the  pressure  on  the  abdominal 
organs,  which  so  deranges  the  circulation  as  to  cause  these  serious 
results.  The  sudden  removal  of  pressure  from  the  vesical  walls, 
which  that  pressure  rendered  anaemic,  now  allows  intense  conges- 
tion, and  the  vesical  walls  being  paralyzed  catarrh  and  cystitis  result. 
Therefore,  for  many  reasons,  a  distended  bladder  should  be  emptied 
slowly. 

When,  for  any  reason,  a  catheter  can  not  be  introduced  into  the 
bladder,  hot  hip-baths  should  be  again  tried,  and  opium  given  in  suf- 
iicient  amount  to  relieve  pain  and  any  spasmodic  action  that  may 
exist.  If,  after  this,  there  is  failure  to  enter  the  bladder  (and  it  is 
only  in  very  rare  cases  that  this  occurs),  recourse  should  be  had  to 
the  aspirator,  and  after  having  punctured  the  bladder,  the  urine 
should  be  drawn  slowly  and  carefully,  in  the  manner  already  de- 
scribed. 

In  commencing  vesical  paralysis,  and  when  incontinentia  para- 
doxa  exists  or  has  existed,  the  patient  should  be  taught  to  use  the 
catheter  herself  several  times  daily  until  the  vesical  power  returns. 

It  is  of  the  utmost  importance  that  the  catheter  be  absolutely 
clean.  After  each  time  that  it  is  used  it  should  be  thoroughly  rinsed 
in  a  chlorine  solution,  and  put  away  in  carbolized  oil  or  vaseline.  A 
great  deal  of  vesical  catarrh  is  undoubtedly  lighted  up  by  foul  cath- 
eters. This  is  especially  the  case  in  hospitals,  where  the  same  in- 
strument is  often  used  on  a  number  of  patients. 

In  cases  of  commencing  or  established  paralysis  the  effect  of  the 
induced  electric  current  may  be  tried.  One  pole  thoroughly  insu- 
lated up  to  the  point  to  be  used  should  be  placed  in  the  bladder, 
and  the  other  over  the  pubic  symphysis  and  loins,  letting  the  cm'- 
rent  flow  in  various  directions,  through,  over,  and  into,  the  affected 
organ.  The  German  authors,  especially  Winckel,  by  whom  this 
method  is  highly  recommended  in  this  and  like  affections,  say  that 
the  sitting  should  last  but  about  five  minutes. 

Forcibly  distending  the  urethra  and  washing  out  the  bladder 
with  a  solution  containing  salicylic  acid  has  been  tried  and  recom- 
mended. I  can  not  see  the  expediency  of  this  unless  vesical  catarrh 
exists ;  and  even  then  washing  must  be  done  gently  and  carefully, 
and  without  previous  dilatation  of  the  urethra. 

Attention  should  be  paid  to  the  general  health.  The  food  should 
be  good  and  nourishing,  and  the  alimentary  canal  kept  in  a  proper 
condition  to  receive  and  digest  it.  Wines  (especially  champagne), 
beer,  and  ale  may  be  of  use.     I  can  at  least  say  if  stimulants  are 


728  DISEASES  OF  WOMEN, 

ever  given  in  diseases  of  the  bladder  it  should  be  in  cases  like  these 
now  under  consideration.  These  patients  are  usually  more  com- 
fortable in  the  standing  or  sitting,  than  in  the  prone  posture,  be- 
cause then  the  weight  of  the  abdominal  viscera  replaces  to  a  cer- 
tain extent  the  natural  tonicity  of  the  organ.  As  they  are  usually 
worse  in  winter  than  in  summer  it  is  advisable,  if  the  case  is 
chronic  and  the  patient  able  to  bear  transportation  and  rich  enough 
to  meet  the  expense,  to  send  her  to  a  moderately  warm  climate 
during  the  winter  months.  This  will  apply  in  most  of  the  diseases 
of  the  bladder. 

If  the  trouble  be  purely  atonic,  camphor  or  musk  may  be  used 
internally.  Tincture  of  cantharides,  in  from  five  to  twenty  drop 
doses,  three  times  a  day,  has  been  recommended  as  a  vesical  excit- 
ant. I  can  not  indorse  its  use  without  the  caution  that  besides  the 
tendency  to  irritate  the  kidneys  and  produce  congestion  and 
nephritis,  it  may  light  up  a  severe  cystitis.  In  these  cases  it  may 
produce  serious  trouble  without  causing  much  pain  to  give  warning 
of  the  danger,  as  the  paralysis  lessens  the  sensitiveness  of  the  blad- 
der, so  that  destruction  of  tissue  may  occur  without  producing  the 
usual  pain  and  suffering. 

Strychnia  has  been  extensively  used  in  this  complaint,  and  with 
good  results  in  some  cases.  Its  failure  to  do  good  in  many  in- 
stances is  undoubtedly  due  to  the  fact  that  it  was  not  given  in  suffi- 
ciently large  doses.  It  may  be  safely  pushed  as  high  as  the  one- 
twentieth  of  a  grain  three  times  a  day,  stopping  for  a  few  days  if 
any  of  its  characteristic  symptoms  appear.  It  has  also  been  used 
hypodermically  in  the  neighborhood  of  the  bladder. 

Ergot  has  been  found  useful  in  cases  where  the  paralysis  was 
due  to  exposure  to  cold,  or  prolonged  retention  from  any  cause. 
The  fresh  powder  has  been  recommended,  and  may  be  given  in  doses 
of  from  eight  to  sixteen  grains,  four  or  five  times  daily.  It  is  more 
pleasant  and  probably  more  effective  to  give  its  equivalent  of  the 
fluid  extract,  Alliers  has  used  it  with  decided  success  in  cases  of 
vesical  paralysis  due  to  centric  troubles,  such  as  apoplexy.  He  has 
used  as  nmch  as  forty-five  grains  in  the  twenty-four  hours.  It  is 
highly  s})oken  of  also  by  Roth,  Jacksch,  and  others. 

Rutenberg  ("  Wienner  Med.  Wochenschrif t,"  1875,  No.  37)  has 
recommended,  in  cases  where  there  is  destruction  of  muscular  tissue 
or  incurable  paralysis  from  any  cause,  to  make  an  opening  into  the 
bladder  just  above  the  pubic  symphysis,  keeping  the  fistula  open, 
and  closing  the  urethra  by  operative  procedures.  The  urine  can 
thus  be  retained,  unless  the  patient  bends  forward  and  downward 


FUNCTIONAL'  DISEASES  OP  THE  BLADDER.  729 

or  lies  upon  lier  abdomen.  A  urinal  would,  of  course,  be  necessary 
to  protect  the  patient. 

I  think  I  should  prefer  to  produce  a  vesico-vaginal  fistula,  and 
adapt  an  apparatus  to  receive  the  urine. 

{b)  Incontinence  of  Urine. — Enuresis  nocturna  is  usually  an  affec- 
tion of  childhood,  but  has  been  known  to  persist  up  to  the  age  of 
thirty  years.  In  some  children  it  is  hereditary,  the  mother  having 
suffered  in  early  years,  and  all  the  children  bom  to  her  being  affected 
in  the  same  way.  Of  all  cases,  these  are  the  most  difficult  to  manage. 
They  often  persist  until  puberty,  when  they  recover  of  themselves. 
The  subjects  of  this  affection  are  usually  of  the  weak,  nervous  type, 
although  apparently  healthy  children  have  been  known  to  suffer 
from  it,  but  usually  only  at  intervals. 

These  cases  of  incontinence  may  be  divided  into  two  distinct 
varieties:  First,  the  anaesthetic  variety.  An  excellent  example  of 
this  class  is  seen  in  infants  who,  up  to  a  certain  age,  wet  the  bed  and 
their  diapers.  In  the  infant  this  is  not  disease  ;  it  is  simply  a  good 
normal  example  of  this  condition ;  the  incontinence  in  severe  fevers 
illustrates  the  abnormal  phase  of  the  same  thing.  Second,  the  hyper- 
aesthetic  variety,  which  is  really  nothing  more  than  irritable  bladder. 
Each  variety  may  exist  alone,  or  both  be  combined  in  the  one  case. 

In  the  first  variety  the  retaining  power  is  defective,  the  resisting 
power  of  the  sphincter  being  insufficient  to  retain  the  urine  or  wake 
the  child.  When  it  is  put  to  bed,  it  sleeps  soundly  through  the 
night,  and  the  nerve  susceptibihty  to  urine-pressure  on  the  neck  of 
the  bladder,  being  lowered  beyond  the  normal  degree,  fails  to  wake 
the  little  subject  and  impress  it  with  the  necessity  of  calKng  the 
sphincter  muscle  into  action  sufficiently  to  resist  the  expulsive  power 
of  the  bladder-walls.  In  short,  in  sound  sleep  the  balance  between 
the  resisting  power  of  the  sphincter  and  the  contractility  of  the  waUs 
of  the  bladder  is  disturbed,  and  the  urine  flows  away  without  the 
child's  even  dreaming  of  its  unfortunate  behavior. 

In  other  forms  of  this  affection  the  brain  takes  cognizance  of  the 
desire  to  urinate,  but  too  late  to  control  the  act.  This  is  seen  in 
children  who  awake  crying  when  urination  is  but  just  begun  or  half 
finished.     In  this  case  the  fault  probably  lies  in  the  vesical  neiTes. 

In  the  second  variety  there  is  an  irritable  condition  of  the  blad- 
der (vesical  hyperaesthesia),  which  renders  the  expelling  power 
greater  than  that  of  resistance  or  retention,  and,  while  the  will  and 
cerebration  generally  are  lost  in  sleep,  the  contents  of  the  bladder 
are  unconsciously  passed  before  the  subject  wakes  to  resist  the  act. 
Closely  allied  to  this  is  the  peculiar  affection  known  as  vesical  chorea, 


730  DISEASES   OF  WOMEN. 

in  which  the  child  while  awake,  it  may  be  in  school,  in  church,  oi 
at  plaj,  suddenly  experiences  the  sensation  that  it  is  about  to  make 
water,  but,  before  it  is  possible  to  resist,  the  urine  is  forcibly  spurted 
out.  There  are  usually  choreic  movements  of  other  muscles  or  groups 
of  muscles.  This  affection  is  the  most  annoying  when  the  little  ones 
are  nervous,  cross,  and  fidgety.  It  may  be  accompanied  by  nocturnal 
enuresis.  It  is  apparently  more  common  in  the  male  than  in  the 
female  child. 

An  irritable  condition  of  the  bladder  may  coexist  with  an  an- 
SBsthetic  condition  of  the  sphincter  vesicae — i.  e.,  the  two  causes  of 
incontinence  may  be  combined. 

Irritable  bladder,  it  should  be  remembered,  may  be  due  to  some 
systemic  condition — that  is,  a  simple  neurosis  or  to  abnormal  urine, 
or  reflex  irritation  from  anal  fissure,  ascarides  in  the  rectum,  fistula 
in  ano,  haemorrhoids,  or  vulvitis. 

Enuresis  noctuma  is  not  only  a  filthy  habit,  and  a  source  of  great 
annoyance  to  parents,  but,  moreover,  by  keeping  the  genitals  wet 
and  irritable,  strongly  predisposes  to  masturbation.  Then,  too,  other 
serious  results  may  happen.  The  constant  wettings  are  dangerous, 
in  that  they  may  produce  many  serious  complaints  from  causing  the 
child  to  "  take  cold." 

Prognosis. — In  some  cases  the  cure  is  easily  and  speedily  ef- 
fected ;  in  others,  the  disease  cures  itself  at  or  just  after  puberty ; 
but  in  a  few — a  very  small  percentage — no  medical  or  other  means 
seem  to  aid  the  sufferer  at  all. 

Treatment. — That  the  treatment  is  not  unifonnly  satisfactory  is 
seen  by  the  number  of  remedies  that  have  been  tried.  The  proper 
way — and  I  can  not  call  attention  to  this  too  often — here,  as  else- 
where, is  to  find  the  cause  producing  the  disease,  if  it  be  discovera- 
ble, and  it  generally  is.  The  treatment  will,  of  course,  differ  in  the 
two  classes,  and  be  greatly  modified  by  diathesis  and  idiosyncrasy. 
In  anaesthesia,  local  or  general,  stimulation  is  indicated.  In  hyper- 
aesthesia,  irritability  should  be  allayed. 

Winckel,  Barclay,  and  Brugleman  speak  very  highly  of  the  use 
of  tlie  syrupus  ferri  iodidi,  the  last-named  gentleman  having  by  its 
use  cured  a  girl  perfectly  of  incontinence  in  the  short  space  of  four- 
teen days.  This  result  was  probably  due  more  to  the  effect  of  the 
medicine  on  the  blood  and  general  system  than  to  any  specific  action 
on  the  bladder.  The  sirup  of  tiie  iodide  may  be  given  in  from  ten 
to  thirty  minim  doses  three  or  four  times  daily,  according  to  the  age 
of  the  patient. 

Althongh  belladonna  has  been  lauded  by  many  as  a  specific  in 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  ^31 

this  disorder,  its  success  is  by  no  means  general.  Tlie  drug  is  usually 
given  by  the  mouth  in  from  iive  to  twenty  drop  doses  of  the  officinal 
tincture.  It  would  be  better  to  begin  with  small  doses  in  young 
children,  and  gradually  increase  them ;  for,  although  no  serious  re- 
sults may  come  from  its  exhibition  in  the  routine  dose — ten  drops — 
the  parents  may  be  greatly  alarmed  by  the  peculiar  redness  of  the 
skin  produced  in  some  cases.  It  is  maintained  by  some  medical  men 
that  the  good  effects  are  not  obtained  unless  the  administration  be 
pushed  to  the  appearance  of  the  scarlet  rash.  There  is,  I  think,  no 
proof  of  the  correctness  of  this  statement. 

A  combination  of  belladonna  and  chloral  hydrate  has  been  used 
and  well  spoken  of.  Winckel,  however,  though  using  them  in  cer- 
tain cases  for  a  long  time,  and  daily  increasing  the  amount  of  chloral, 
has  had  but  poor  results,  and  even  in  those  cases  where  the  patients 
improved  the  benefit  was  seldom  permanent.  These  drugs  may  be 
given  singly  or  together,  in  suppository  or  by  the  mouth.  If  given 
together,  they  should  not  be  combined  until  the  time  when  they  are 
administered,  lest  the  chloral  lose  its  power. 

JSTarcotics  with  tinctura  ferri  chloridi  have  been  recommended 
by  Campbell  Black.  Winckel  speaks  well  of  five  to  ten  drop  doses 
of  tinctura  thebaica,  to  a  child  from  ten  to  fourteen  years  of  age,  just 
before  retiring.  According  to  Sauvage,  cold  baths  and  cold  douches 
to  the  spine  at  night  are  of  great  service. 

Dr.  Xelp  ("  Le  Mouvement  Med.")  reports  that  he  has,  on  sev- 
eral occasions,  drawn  attention  to  the  value  of  subcutaneous  injec- 
tions of  the  nitrate  of  strychnia  in  the  treatment  of  obstinate  cases 
of  nocturnal  incontinence.  He  practices  the  injections  in  the  neigh- 
borhood of  the  sacrum.  A  single  injection  of  a  very  small  quantity 
of  the  drug  suffices  to  arrest  the  affection  for  a  certain  time,  and 
w^hen  it  reappears  the  operation  can  be  repeated.  His  latest  paper 
cites  the  case  of  a  young  woman,  eighteen  years  of  age,  who  had 
suffered  from  enuresis  every  night  for  several  months ;  it  came  on 
after  an  attack  of  scarlatina,  and  persisted  in  spite  of  all  precautions. 
The  first  injection  produced  a  respite  of  several  nights,  and  the 
second  produced  a  permanent  cure.  The  patient  was  a  strong, 
healthy  girl,  and  had  never  suffered  from  enuresis  previous  to  the 
attack  of  scarlatina. 

Such  a  plan  of  treatment  I  regard  as  useful  only  when  there  is 
deranged  innervation,  characterized  by  weakness.  It  would  be  diffi- 
cult to  get  a  child  to  submit  to  these  injections,  and  I  should  in  any 
case,  whether  child  or  adult,  expect  the  incontinence  to  return  as 
soon  as  the  strychnia  was  discontinued. 


732  DISEASES  OF  WOMEN. 

In  cases  where  the  vesical  irritability  is  due  to  abnormality  of 
the  urine,  such  as  lithiasis,  oxaluria,  and  acidity,  these  conditions 
should  be  corrected  in  the  manner  I  have  already  pointed  out.  If 
to  ascarides,  anal  fissure,  and  that  class  of  rectal  trouble,  when  the 
cause  is  removed  the  result  will  usually  disappear  also.  In  irrita- 
bility the  usual  soothing  and  demulcent  drinks,  such  as  have  been 
already  recommended,  should  be  used.  Oil  of  sandal-wood  has  acted 
remarkably  well  in  some  of  these  cases.  Bromide  of  sodium  and 
tincture  of  nux  vomica  have  been  effectual  in  some  cases. 

In  the  anaesthetic  variety,  where  the  anaesthesia  is  more  or  less 
marked,  special  or  local  and  general  stimulants  should  be  employed. 
Narcotics  are  as  hurtful  here  as  they  are  useful  in  the  hyperaesthetic 
class.  Strychnia  by  the  mouth,  in  suppository,  or  hypodermically, 
often  produces  good  results,  as  also  quinine,  whether  the  presence 
of  malaria  is  suspected  or  not.  Tonic  and  astringent  injections  into 
the  bladder  are  sometimes  of  service.  In  cases  of  abnormally  small 
bladder,  forcibly  washing  it  out,  distending  the  organ  a  little  more 
each  time,  is  well  spoken  of.  In  one  such  case,  where  there  was 
irritability,  Winckel  produced  a  cure  by  first  injecting  a  solution  of 
nitrate  of  silver,  and  following  it  with  sulphate  of  morphia.  This 
treatment,  however,  applies  more  to  the  irritable  than  to  the  anaes- 
thetic type.  The  little  patients  are  very  hard  to  operate  upon,  and, 
unless  great  care  is  exercised,  much  mischief  may  be  caused  by  local 
treatment. 

Winckel  claims  good  results  from  the  use  of  the  electric  current, 
applied  in  the  manner  I  have  spoken  of  under  the  head  of  paresis 
vesicae. 

When  the  bed-wetting  is  due  to  pure  carelessness,  laziness,  fear, 
or  dread  of  the  cold  air  in  rising,  in  idiots  and  half-witted  children,^ 
much  may  be  gained  by  proper  education. 

There  is  a  general  plan  of  prophylaxis  recommended  by  common 
sense,  viz.,  the  heartiest  meal  should  be  in  the  middle  of  the  day; 
but  little  water  should  be  taken  toward  evening ;  the  food  should  be 
plain  and  unseasoned ;  the  bowels  should  be  kept  regular ;  no  coffee 
or  tea  should  be  allowed ;  the  little  patients  should  be  put  to  bed 
early,  after  it  is  assured  that  the  bladder  is  first  thoroughly  emptied  ; 
they  should  lie  upon  a  hard  bed,  with  not  too  much  covering ;  the 
air  in  the  room  should  be  maintained  fresh  and  pure ;  the  genitals 
should  be  kept  clean  and  dry ;  no  places  of  amusement  should  be 
visited  after  dark ;  and  they  should  be  awakened  occasionally  to 
urinate,  especially  at  about  the  time  the  parents  are  going  to  bed. 
When  it  is  discovered  that  they  have  wet  the  bed,  they  should  be 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  733 

awakened,  aud  talked  to  and  reasoned  with,  if  they  are  able  to  com- 
prehend what  is  said  and  meant.  Children  should  not  go  to  school 
too  early,  or  stay  too  long.  If  the  enuresis  be  due  to  masturbation, 
the  parents  must  be  cautioned  to  watch  closely,  and  to  use  every 
means  in  their  power  to  stop  it.  A  child  should  never  be  whipped 
for  the  offense  or  misfortune  of  wetting  the  bed,  unless  the  inconti- 
nence be  due  to  pure  laziness. 

Owing  to  the  fact  that  incontinence  is  an  affection  of  childhood, 
and  occurs  but  seldom  in  women,  cases  will  not  be  given  to  illustrate 
what  is  said  in  the  text  on  that  subject.  This  omission  is  made  for 
the  additional  reason  that  partial  incontinence  due  to  displacements 
of  the  bladder  aud  urethra  and  from  other  causes  will  be  discussed 
further  on, 

ILLUSTRATIVE    CASES, 

Paralysis  of  the  Bladder  followed  by  Incontinence  in  Case  of  In- 
sanity.— This  was  a  single  lady,  twenty-eight  years  of  age,  who  had 
been  insane  for  eight  months.  I  was  told  that  at  first  she  was  vio- 
lent, but  had  become  quiet  and  rather  demented  toward  the  time 
that  I  saw  her.  Her  physician  had  observed  for  some  time  that  her 
bowels  were  obstinately  constipated,  and  the  nurse  noticed  that  she 
had  great  difficulty  in  evacuating  the  bladder.  She  also  appeared 
to  have  some  discomfort  in  that  region ;  finally,  she  went  for  over 
twenty-four  hours  without  urinating,  and  then  I  was  called  to  see 
her.  I  found  the  bladder  greatly  distended,  and  yet  I  could  not  see 
that  she  had  pain  or  tenderness  on  that  account.  The  catheter  was 
used,  and  three  and  a  half  pints  of  urine  were  removed.  After  this 
the  catheter  had  to  be  used  twice  in  twenty-four  hours  for  five  weeks. 
During  this  time  the  usual  means  were  tried  to  restore  the  function 
of  the  bladder,  but  without  effect.  The  urine  then  began  to  flow 
constantly.  When  I  heard  of  this,  I  presumed  that  the  bladder  had 
become  overdistended,  and  that  the  nurse  who  used  the  catheter  had 
not  emptied  the  bladder.  This  I  found  was  not  the  case ;  the  blad- 
der was  empty.  The  incontinence  continued  until  the  patient  died 
of  general  paralysis. 

Paralysis  of  the  Bladder  from  Cerebro-spinal  Meningitis. — A  girl 
twelve  years  old  was  taken  with  cerebro-spinal  meningitis,  and  pre- 
sented the  usual  clinical  history  of  that  affection  until  the  seventh 
day  of  the  disease,  at  which  time  the  pain  had  subsided  to  a  great 
extent,  but  her  mind,  which  up  to  this  time  had  been  clear,  began 
to  wander.  Retention  of  the  urine  was  noticed  by  her  nm'se,  who 
called  my  attention  to  the  fact.     I  found  the  bladder  distended,  but 


734  DISEASES  OF  WOMEN. 

not  greatly  so.  She  was  asked  if  she  did  not  desire  to  urinate,  but 
she  answered  in  the  negative,  so  far  as  I  could  understand  her.  The 
catheter  was  used,  and,  although  the  distention  was  not  great,  the 
bladder  did  not  contract  well,  so  that  abdominal  pressure  was  neces- 
sary to  make  the  urine  flow  through  the  catheter.  The  use  of  the 
catheter  was  necessary  for  some  time,  during  which  she  improved  in 
her  general  condition,  the  mind  becoming  quite  clear.  She  then 
began  to  express  at  times  a  desire  to  urinate,  but  could  not  relieve 
herself.  Four  days  later  she  succeeded  in  urinating,  but  did  not 
completely  empty  the  bladder.  She  gradually  improved,  but  the 
catheter  was  passed  once  every  twenty-four  hours  for  a  week  longer. 
The  desire  to  empty  the  bladder  became  more  and  more  urgent,  and 
she  had  pain  in  the  urethra  in  urinating.  An  examination  of  the 
urine  at  this  time  showed  that  she  had  cystitis,  due,  I  believe,  to  the 
use  of  the  catheter.  The  cystitis  was  treated  according  to  my  usual 
methods,  and  she  made  a  good  recovery. 

Paralysis  of  the  Sladder  from  Progressive  Locomotor  Ataxia. — A 
lady  who  had  been  affected  with  locomotor  ataxia  for  more  than  a 
year,  came  under  my  care  for  retention  of  urine.  I  found  that  there 
was  some  decomposition  of  the  urine,  but  nothing  else  to  distinguish 
the  case  from  paralysis  of  the  bladder,  occurring  in  other  cases  of 
disease  and  injury  of  the  spinal  cord.  The  attendant  was  advised 
to  use  the  catheter  regularly,  and  to  wash  out  the  bladder  with  a 
solution  of  borax — one  drachm  of  borax  to  a  quart  of  warm  water. 
I  learned  subsequently  that  this  patient  had  incontinence  of  urine 
before  she  died„ 

II.  Derangements  due  to  Abnormal  Conditions  of  the  Urine. — The 
bladder  being  made  to  contain  urine,  almost  constantly  uniform  in 
its  composition,  it  at  once  feels  and  responds  to  any  abnormality. 
If  the  aberration  is  only  occasional,  the  effects  are  slight  and  of  short 
duration  ;  but,  if  the  abnormality  be  constant,  or  almost  so,  or  if  the 
altered  urine  has  a  hypersesthetic  surface  to  deal  with,  the  results  are 
more  annoying. 

Urine  which  is  too  acid  or  too  alkaline,  too  limpid  or  too  greatly 
concentrated,  acts  somewhat  like  a  foreign  body — it  irritates,  and 
the  bladder  inclines  to  expel  it. 

Deposits  of  any  of  the  urinary  solids  in  the  viscus  may  produce 
an  irritaljle  condition,  and,  if  unchecked,  lead  to  organic  disease  of 
the  bladder.  Uric  acid,  in  large  or  small  crystals,  in  little  masses, 
forming  gravel  and  minute  calculi,  the  amorphous  urates,  the  triple 
and  amorphous  phosphates  (tliese,  as  a  rule,  however,  occurring  only 
in  decomposition  of  the  urinej,  and  oxalate  of  lime  may  give  rise  tc 


FUNCTIONAL  DISEASES   OP  THE  BLADDER.  735 

considerable  trouble.  There  are  some  other  deposits,  such  as  cystine,^ 
that  are  of  such  rare  occurrence  that  they  need  not  be  mentioned  in 
this  list.  In  any  of  these  cases^  but  especially  when  there  is  a  de- 
posit of  uric  acid,  there  may  be  one  of  two  things  resulting;  and, 
in  order  to  treat  tho  case  properly,  they  must  be  borne  in  mind : 
First,  a  real  excess  of  the  salt  in  the  urine ;  and  second,  a  condition 
of  the  secretion,  where,  whether  the  amount  of  salt  present  be  nor- 
mal, or  less  or  more  than  normal,  it  will  be  precipitated  in  the  blad- 
den 

As  an  example  of  the  first  may  be  mentioned  some  cases  of  dys- 
pepsia, when,  owing  to  a  defect  in  either  primary  or  secondary  as- 
similation, the  salt  or  salts  are  eliminated  by  the  kidneys  greatly  in 
excess  of  the  normal.  Here  a  normal  or  even  an  abnormal  amount 
of  water  in  the  secretion  could  not  hold  them  in  solution,  and  they 
are  consequently  precipitated. 

As  an  example  of  the  second  may  be  taken  some  cases  of  hepatic 
disease,  in  which,  although  the  uric  acid  is  eliminated  in  abnormally 
small  amount,  it  is  precipitated  on  account  of  the  deficiency  of  water, 
excessive  acidity,  and  possibly  too  rapid  absorption  of  the  watery 
element  of  the  urine  while  in  the  bladder. 

In  some  cases  with  an  excess  of  salts,  there  may  be  excessive 
acidity  and  lack  of  water.  Some  forms  of  dyspepsia  are  notable 
examples  of  this,  and  as  low  nerve  condition  frequently  accompanies 
these  disorders,  the  abnormal  urine  meets  in  the  bladder  with  an 
irritable  mucous  membrane.  In  these  cases  the  acidity  is  quite  as 
hurtful  as  the  deposit. 

Deposits  of  oxalate  of  lime  in  the  bladder  are  not  so  common 
(except  in  lime-water  regions)  as  those  of  uric  acid.  In  cases  of  the 
persistent  deposit  of  oxalate  of  lime  in  the  urine,  known  as  oxaluria, 
there  is  usually  marked  irritability  of  the  bladder.  This  has  been 
ascribed  by  some  to  the  presence  of  minute  octahedra  of  this  salt 
irritating  the  mucous  membrane.  It  is  more  than  likely,  however, 
that  the  derangement  of  the  general  nervous  system,  always  existing 
in  these  cases,  stands  as  a  propter  rather  than  a  post  hoc,  and  that 
the  bladder  difiiculty  is  but  a  local  manifestation  of  the  general  dis- 
ease, and  consequently  a  pure  neurosis.  That  the  urine  of  oxaluria 
does  possess  irritant  properties  there  is  but  little  doubt,  but  it  is 
hardly  likely  that  the  symptoms  here  occurring  would  be  produced 
unless  there  was  already  an  abnormal  condition  of  the  vesical  mucous 
membrane. 

Many  authors  hold  that  the  high  specific  gravity  of  a  single  speci- 
men of  urine  must  not  be  taken  as  an  evidence  of  concentration,  oj 


736  DISEASES  OF  WOMEN. 

the  low  gravity  of  excessive  limpidity  of  the  twenty-four  hours' 
urine.  This  is  very  true  in  regard  to  the  total  amount  passed  in  a 
day ;  but  as  the  bladder  has  to  do  each  time  only  with  the  urine  in 
it  at  that  time,  it  will  be  well  in  these  cases  to  examine  several  spec- 
imens in  a  day,  rather  than  to  depend  for  information  on  the  reac- 
tion of  the  total  amount  of  urine  passed. 

Urine  may  irritate  the  same  patient  at  one  time  from  being  too 
limpid,  and  at  another  time  from  being  too  highly  concentrated. 
These  variations  must  be  carefully  watched  and  treated.  A  bladder 
that  is  irritable  at  all  times  and  witli  urine  of.  varying  reactions, 
may  be  set  down  as  one  affected  with  a  pure  neurosis,  if  no  organic 
cause  be  found,  for  the  urine  could  not  work  the  mischief  continu- 
ally, if  normal  at  certain  periods. 

Symjptomatology. — Patients  suffering  from  this  affection  usually 
complain  of  frequent  urination  and  vesical  tenesmus. 

In  some  cases  there  is  smarting  pain  in  the  urethra  during  the 
passing  of  water  and  for  some  time  after,  and  there  is  a  sense  of  heat 
in  the  bladder  and  a  desire  to  urinate  which  are  not  fully  relieved 
when  the  bladder  is  empty.  This  last-named  symptom  belongs 
more  especially  to  those  cases  in  which  the  urine  salts  are  in  excess. 
When  the  urine  is  defective  in  the  salts,  that  is,  when  the  urine  is 
limpid,  the  only  symptom  present  is  frequent  urination.  It  will  be 
observed  that  these  symptoms  are  the  same  as  those  presented  in  a 
variety  of  affections,  and  hence  can  not  be  depended  ujion  in  making 
a  diagnosis. 

Diagnosis. — The  diagnosis  must  be  made  by  excluding  all  other 
conditions  which  give  rise  to  this  derangement  of  function,  and  by  re- 
peated examinations  of  the  urine,  which  will  show  its  abnormal  state. 

Prognosis. — The  relief  of  this  class  of  cases  will  depend  upon 
the  possibility  of  correcting  the  constitutional  affections  which  pro- 
duce the  pathological  state  of  the  urine. 

In  case  the  abnormalities  of  the  urine  persist  for  a  long  time 
cystitis  and  urethritis  may  be  produced.  I  am  sure  that  I  have  seen 
cystitis  which  could  be  traced  to  long  continued  abnormal  states  of 
the  urine. 

Causation. — In  discussing  tlie  pathology  of  this  class  of  func- 
tional derangements  the  causes  which  produce  them  liave  been  fully 
brought  out,  so  that  they  need  not  be  repeated  here. 

Treatment. — In  cases  of  concentration  of  the  urine  due  to  acute 
febrile  action,  the  patient  should  be  liberally  supplied  with  cooling 
drinks ;  and  as  in  these  affections  the  urine  is  generally  too  acid,  the 
slightly  alkaline,  effervescing  waters  will  be  found  useful. 


FUNCTIONAL  DISEASES   OF  THE  BLADDER.  737 

In  digestive  troubles,  with  excessive  acidity  or  saline  deposit,  at- 
tention slioiild  be  paid  to  diet,  bathing,  and  regularity  of  the  bow- 
els, as  well  as  the  taking  of  a  proj)er  amount  of  exercise,  Wliere 
deposits  of  uric  acid  take  place  there  is  usually  some  defect  in  either 
primary  or  secondary  assimilation.  This  should  be  sought  out  and 
remedied.  In  excessive  acidity  with  deposits  of  uric  acid,  the  alka- 
line carbonates  act  in  a  double  way  ;  first  by  neutralizing  the  acid- 
ity of  the  urine,  and  second  by  acting  on  the  liver  to  lessen  the 
amount  of  uric  acid  produced.  The  following  is  a  very  pleasant 
and  efficient  prescription  in  these  cases. 
1^.     Potassii  bicarbonatis, 

Potassii  citratis aa  3  ss. 

Syrupi  simplicis 3  i^. 

M.  

Sig.  Take  3i  in  half  a  tumbler  of  water,  adding  3ij  of  lemon- 
juice.     Drink  while  effervescing. 

The  late  Prof,  Armor  gave  some  very  excellent  advice  regarding 
the  management  of  such  cases,  which  I  will  reproduce  in  his  own 
words : 

"  When  the  urine  is  acid  in  any  of  the  forms  of  cystic  irritation, 
great  relief  is  experienced  from  the  use  of  alkalies,  especially  when 
administered  in  an  infusion  of  buchu,  I  regard  buchu  as  a  remedy 
of  undoubted  efficacy  in  all  cases  of  vesical  irritability.  It  seems 
to  possess  similar  properties  over  the  urinary  tract  that  bismuth  does 
over  the  intestinal,  and  is  an  admirable  vehicle  in  which  to  adminis- 
ter the  various  alkalies.  The  citrate  of  potash  with  buchu  is  an  excel- 
lent combination  where  we  desire  the  joint  action  of  these  remedies. 
The  liquor  of  potash,  the  bicarbonate  and  the  iodide  of  potash  also 
possess  a  high  degree  of  utility  in  the  class  of  cases  refei-red  to,  and 
their  therapeutic  action  is  certainly  never  disturbed  by  administer- 
ing them  in  an  infusion  of  buchu, 

"  In  irritable  conditions  of  the  bladder  associated  with  a  gouty 
and  lithic-acid  diathesis,  the  carbonate  of  lithium  is  a  remedy  of  un- 
doubted efficacy.  It  perhaps  excels  the  preparations  of  potash  in 
rendering  uric  acid  and  the  urates  soluble," 

The  following  is  the  formula  of  a  prescription  which  answers 
well : 

5,.     Lithise  carbonatis 3  ij- 

Acidi  benzoic •    3  iij- 

Sodii  boratis 3  j- 

Aqu?e  dest 3  i^"- 

M,     Sig.  One  teaspoonf  ul  in  a  large  glass  of  water. 
48 


738  DISEASES  OF  WOMEN. 

Limpid  urine  is  usually  due  to  some  general  nervous  trouble  or 
cerebral  disease.  In  such  cases  treatment  should  be  directed  to  the 
original  disease. 

Deposits  of  amorphous  or  triple  phosphates  are  rare,  unless  there 
is  some  organic  disease  of  the  bladder.  Where  the  deposits  are  not 
due  to  decomposition,  some  decided  nerve  trouble  is  usually  pres- 
ent, and  here,  as  in  limpidity,  the  attention  must  be  turned  to  treat- 
ment of  the  general  trouble. 

In  oxaluria  attention  nmst  be  paid  to  the  moral,  mental,  and 
physical  condition,  and  time  must  not  be  wasted  in  treating  mere 
symptoms.  In  the  way  of  medication,  the  following  prescription 
is  looked  upon  by  many  as  almost  specific  in  these  cases  : 

9..     Acidi  nitro-muriatici  diluti 3  v-vj. 

Tincturge  nucis  vomicae 3  iij- 

Olei  gaultherise TTLxij. 

Aquse  ad 5  iv. 

M.  

Sig. —  3  i  in  water  before  each  meal.  In  some  cases  the  pure 
non-diluted  acid,  freshly  made  up,  acts  better  than  the  dilute.  It 
should  be  given  in  smaller  doses  than  the  dilute,  and  in  plenty  of 
water  at  the  time  of  taking  it.  In  all  cases  of  urinary  deposits, 
water  should  be  freely  taken,  and  the  greatest  attention  paid  to 
general  hygiene  and  to  mental  and  moral  surroundings. 

Many  of  the  slightly  alkaline  mineral-spring  waters  will  be  found 
of  use,  acting  gently  on  the  liver,  flushing  the  kidneys  and  urinary 
organs,  and  slightly  relaxing  the  bowels.  A  considerable  quantity 
should  be  taken  in  the  course  of  the  day  when  the  stomach  is  empty. 

ILLUSTRATIVE    CASES. 

Irritation  of  the  Bladder  from  Abnormal  Urine. — A  patient  forty 
three  years  old,  large  and  stout,  had  menstruated  scantily  for  sev- 
eral months  and,  as  the  flow  diminished  in  quantity  and  duration, 
she  gained  in  flesh  but  not  in  strength.  She  had  a  very  good  appe- 
tite and  lived  very  well,  but  she  did  not  feel  in  her  usual  health. 
She  noticed  a  gradual  disinclination  to  mental  and  physical  activity. 
Backache,  headache,  and  wandering  pains  here  and  there,  occasionally 
annoyed  her.  After  these  symptoms  had  continued  for  a  time  urin- 
ation became  more  frequent  and  at  times  slightly  painful.  She 
noticed  also  that  there  was  a  sediment  in  the  urine.  These  symp- 
toms caused  her  to  seek  advice  from  the  fear  that  she  had  Bright's 
disease.  She  was  found  to  possess  a  very  good  organization  ;  and 
there  was  no  organic  disease  of  any  kind  present.     All  the  evi- 


FUNCTIONAL  DISEASES  OF   THE   BLADDER.  739 

dences  of  excrementitious  plethora  were  well  expressed  in  the  abun- 
dant adipose  tissue,  coated  tongue,  constipation,  muddy  appear- 
ance of  the  eyes,  full  slow  pulse,  shortness  of  breath  on  exertion, 
depression  of  spirits,  disposition  to  sleep,  and  at  times  sleepless- 
ness. The  urine  was  examined,  and  found  to  be  slightly  alkaline. 
The  specific  gravity  was  1030.  There  was  neither  albumen  nor 
casts.  The  salts  of  the  urine  were  in  excess,  but  as  a  quantitative 
analysis  was  not  made  the  exact  composition  of  the  urine  was  not 
obtained.  The  diagnosis  of  general  excrementitious  plethora  from 
imperfect  elimination  was  made,  and  the  frequent  urination  was  at- 
tributed to  the  abnormal  condition  of  the  urine.  Ten  grains  of  pil. 
hydrarg.  and  one  grain  of  ipecac  were  given  at  bed-time  and  a  Seid- 
litz  powder  an  hour  before  breakfast  the  next  morning.  This  was 
repeated  in  five  days. 

The  quantity  of  food  was  diminished — she  had  been  taking  ex- 
tra diet  to  make  her  stronger — milk  was  the  chief  article  permitted, 
with  a  very  little  animal  food  once  a  day.  A  Turkish  bath  twice  a 
week  and  gradually  increased  out-of-door  exercise.  The  bowels 
were  kept  rather  free  by  giving  a  dose  of  Congress  water  an  hour 
before  breakfast  every  morning.  Under  this  treatment  she  im- 
proved in  every  way.  The  irritation  of  the  bladder  subsided,  and 
has  not  returned.     The  urine  is  now  normal. 

Frequent  Urination  from  Abnormal  Urine. — An  unmarried  lady, 
thirty  years  old,  of  good  constitution,  very  ambitious  and  energetic, 
overtaxed  herself  during  the  winter,  and  toward  the  end  of  the 
season,  began  to  suffer  from  frequent  urination  and  a  sense  of  burn- 
ing heat  in  the  bladder  and  urethra  after  urinating.  After  a  time 
these  symptoms  became  very  annoying,  and  as  she  was  a  nervous, 
sensitive  person,  she  suffered  quite  severely.  She  was  found  to  be 
quite  out  of  health.  Her  appetite  was  poor  and  her  digestion  im- 
paired ;  she  was  constipated,  and  suffered  from  rheumatic  pains  in 
her  joints,  and  in  the  back  of  her  neck.  In  short,  she  gave  a  fairly 
good  history  of  dyspepsia  and  neurfesthenia  plus  the  irritation  of 
the  bladder  which  was  her  chief  source  of  discomfort.  The  urine 
was  diminished  in  quantity,  dark  in  color,  very  acid,  aid  of  high 
specific  gravity  ;  no  albumen  or  casts  were  found.  She  had  been 
quite  free  from  any  affections  of  the  pelvic  organs,  the  present  dis- 
turbance of  the  bladder  being  the  only  suffering  she  had  ever  had  in 
that  regard. 

My  first  impression  was  that  she  had  cystitis,  but  there  were  no 
products  of  inflammation  found  in  the  urine,  and  therefore  the  diag- 
nosis was  made  as  stated  above. 


740  DISEASES  OF  WOMEN. 

Peptonized  milk  was  ordered  witli  raw  eggs,  and,  in  addition, 
barley  gruel,  clear  soups,  and  bread.  Two  drops  of  liquor  ammonite 
in  a  wine-glass  of  water  were  given  every  two  hours  until  the  urine 
became  normal.  Her  bowels  were  kept  regular  by  small  doses  of 
Rochelle  salts  and  cream-of-tartar  taken  in  the  morning. 

Rest  was  insisted  upon,  and  massage  every  third  day.  As  soon 
as  the  urine  became  less  acid  and  dense,  she  obtained  some  relief, 
but  was  not  restored  to  her  usual  condition.  It  was  not  until  her 
general  health  had  been  improved  that  the  urine  became  normal  and 
the  irritation  of  the  bladder  finally  left.  An  interesting  point  in  the 
treatment  was  observed.  For  a  time  she  was  partially  relieved  by 
the  alkaline  remedies,  but,  when  she  ceased  taking  them,  the  irrita- 
tion of  the  bladder  returned. 

When  her  general  health  was  restored  by  rest  and  tonics  the 
urine  became  normal,  and  the  irritation  of  the  bladder  disappeared 
entirely. 

At  the  present  time  I  have  a  lady  under  treatment  for  specific 
disease  of  the  uterus ;  during  the  last  four  weeks  she  has  had  irrita- 
tion, causing  frequent  urination.  She  obtains  relief  by  drinking 
very  freely  of  lithia  water. 

Case  of  Baruria  (by  Dr.  Samuel  West). — The  patient,  aged  thirty- 
nine,  complained,  after  catching  cold,  of  pains  and  aching  in  her 
limbs,  which  became  severe  enough  after  a  week  to  keep  her  in  bed. 
When  admitted,  these  pains  continued,  but  there  was  swelling  of 
joints.  The  temperature  was  100°,  and  she  perspired  freely,  but  the 
sweat  did  not  smell  sour.  The  urine  had  a  specific  gravity  of  1040, 
and  yielded  copious  crystals  of  nitrate  of  urea,  with  nitric  acid.  Her 
appetite  had  been  for  some  days  almost  absent,  and  in  the  hospital 
she  took  but  a  little  milk  or  beef-tea.  For  two  days  the  condition  of 
the  urine  was  the  same,  and  the  percentage  of  urea  5"1.  This  per- 
centage gradually  fell  to  normal,  and,  as  it  did  so,  all  the  patient's 
symptoms  disappeared.  The  case  was  regarded  as  one  of  baniria. 
The  account  of  the  case  given  by  Prout  was  summarized  and  com- 
pared with  the  present  case,  and  reference  was  made  to  other  authors, 
by  some  of  whom  the  existence  of  the  affection  was  questioned, 
while  by  others  it  was  not  referred  to.  A  somewhat  similar  case, 
the  result  of  overfeeding  and  constipation,  has  been  described,  in 
which  like  symptoms  were  associated  with  a  high  percentage  of  urea, 
and  disappeared  when  the  amount  became  normal. 

III.  Derangements  of  Function  due  to  Affections  of  the  Pelvic 
Organs  other  than  the  Bladder. — Functional  diseases  of  the  bladder, 
caused  by  disorders  of  the  neighboring  pelvic  organs,  are  frequentl? 


FUNCTIONAL  DISEASES  OF   THE  BLADDER.  ^41 

met  with  in  practice.  In  this  class  the  vesical  trouble  is  secondary 
to  some  primary  and  more  important  affection,  but  the  derangement 
of  its  function  is  often  the  most  prominent  and  troublesome  symp- 
tom ;  hence  it  is  important  to  understand  its  relation  to  the  primary 
disease,  in  order  to  make  a  correct  diagnosis,  and  to  treat  such  cases 
properly. 

This  class  of  functional  disorders  frequently  resembles  in  history 
some  of  the  organic  diseases  of  the  bladder,  so  that  care  is  necessary 
to  distinguish  the  one  from  the  other.  What  I  may  say  upon  the 
subject  will  have  reference  to  diagnosis  only.  When  we  know  that 
the  bladder  trouble  is  due  to  disease  of  some  other  organ,  attention 
is  at  once  turned  to  the  primary  affection.  These  facts  must  be 
borne  in  mind,  and  the  symptoms  not  mistaken  for  the  disease. 

Diseases  of  the  rectum  affect  the  bladder  sympathetically.  Irri- 
tation and  pain  in  the  rectum  from  any  cause  affect  the  bladder  more 
or  lesSo  Chronic  hsemorrhoids  will  cause  frequent  urination,  and 
so  will  rectal  fissure,  especially  after  defecation.  Abscesses  in  the 
neighborhood  of  the  rectum  will  frequently  cause  retention  of  urine. 

One  very  interesting  case  of  this  kind  occurred  in  the  practice 
of  my  friend  Dr.  Gushing.  The  patient  had  an  abscess  in  the  neigh- 
borhood of  the  rectum  which  caused  retention  of  the  urine,  and  this 
in  turn  caused  acute  renal  disease.  After  the  bladder  had  been 
emptied  and  kept  from  overdistention  for  some  time,  the  urine  was 
examined  and  found  to  contain  albumen  and  casts.  She  made  a 
rapid  recovery,  and  all  evidence  of  kidney-disease  soon  disappeared. 

Yery  troublesome  vesical  irritation  may  come  from  ascarides. 
The  itching  of  the  anus  and  rectum,  caused  by  these  troublesome 
little  worms,  keeps  up  an  almost  constant  desire  to  urinate.  Chil- 
dren are  most  troubled  with  these  parasites,  but  women  often  suffer 
in  the  same  way. 

Marion  Sims  points  out  the  interesting  fact  that  almost  all  cases 
of  vaginismus  are  accompanied  by  an  irritable  condition  of  the  blad- 
der, and  that,  as  the  terminal  fibers  of  the  hymen  often  extend  from 
the  meatus  to  the  vesical  neck,  cystospasm  may  in  these  cases  be  due 
to  reflex  nerve  irritatioUo  An  attempt  to  catheterize  these  patients 
is  as  liable  to  cause  spasm  of  the  bladder  as  an  analogous  attempt  to 
examine  the  uterus  would  be  to  produce  vaginismus.  In  these  cases 
the  hymen  should  be  excised,  and  the  vaginismus  treated  after  the 
usual  methods. 

Acute  pelvic  peritonitis  and  cellulitis  cause  great  distress  in  many 
cases  by  their  effect  on  the  bladder.  A  constant  desire  to  urinate, 
without  the  ability  to  make  sufficient  straining  effort  to  accomplish 


Y42  DISEASES  OF  WOMEN. 

the  object,  is  very  often  observed  in  all  these  acute  pelvic  inflamma- 
tions. Thedisturbance  of  the  bladder  is,  of  course,  only  a  symptom 
of  the  primary  and  more  important  trouble,  and  simply  requires  to 
be  mentioned  here.  The  after-effects  of  pelvic  peritonitis  are  what 
I  especially  desire  to  call  attention  to  at  present. 

The  adhesions  formed  by  the  products  of  the  inflammation  of 
the  pelvic  peritonaeum  are  in  some  cases  sufficient  to  prevent  the 
normal  filling  of  the  bladder,  and  frequent  urination  then  becomes 
a  necessity.  This  derangement  of  function  generally  exists  alone. 
The  urine  is  retained  without  trouble  up  to  a  certain  amount ;  it  is 
passed  without  pain,  and  no  vesical  tenesmus  follows  evacuation. 
Unless  the  contraction  of  the  bladder  is  great,  and  the  frequent 
necessity  to  urinate  very  troublesome,  patients  rarely  consult  a  J)hy- 
sician  for  it. 

Paralysis  of  the  bladder  with  retention  may  be  caused  by  a  pecul- 
iar condition  of  oedema,  by  which  the  detrusors  are  rendered  power- 
less to  act.  It  is  usually  caused  by  disease  of  the  cervix  uteri,  para- 
metritis, or  peritonitis. 


CHAPTER  XLI. 

METHODS  OF  EXPLORATION  OF  THE  BLADDER  AND  URETHRA. 

Preparatory  to  the  study  of  organic  diseases  of  the  bladder  and 
urethra,  I  desire  to  call  attention  to  the  methods  and  means  of  ex- 
ploring the  bladder  and  urethra,  and  to  some  of  the  physical  signs 
of  disease  obtained  thereby. 

In  all  cystic  affections  the  urine  should  be  carefully  examined, 
both  chemically  and  microscopically.  It  is  not  necessary  for  me  to 
describe  the  methods  to  be  employed  in  this  examination ;  they  will 
be  found  in  the  various  books  published  on  that  subject.  I  may, 
however,  in  passing,  state  that  the  condition  of  the  kidneys  is  better 
determined  by  ascertaining  the  quantity  of  urea  eliminated  than  by 
examining  for  albumin  or  casts.  This  will  be  referred  to  again  in 
discussing  the  diagnosis  of  cystitis. 

If  an  examination  of  the  urine  does  not  make  the  diagnosis  clear, 
attention  should  be  directed  to  a  physical  exploration  of  the  bladder 
and  urethra.  For  this  purpose  either  a  digital  or  an  endoscopic  ex- 
amination may  be  made.  Digital  examination  per  vaginam  is  one 
of  the  most  valuable  means  of  investigating  the  bladder  and  urethra. 
By  this  and  by  the  bimanual  touch  the  physical  signs  of  many  of  the 
affections  of  these  organs  can  be  readily  obtained. 

The  method  of  making  these  examinations  is  exactly  the  same  as 
practiced  in  examining  the  uterus.  The  vaginal  touch  reveals  the 
position  of  the  bladder  and  urethra,  the  degree  of  their  sensitiveness, 
the  location  of  tenderness,  if  any  is  present,  the  increase  or  diminu- 
tion of  elasticity,  and  the  state  of  their  walls,  as  regards  thickening 
or  irregularity.  Distortions  of  the  urethra  from  neoplasms  or  the 
products  of  inflammation  can  also  be  detected  in  this  way. 

The  bimanual  touch  will  show  whether  the  bladder  is  full,  empty, 
or  partially  distended,  and  any  foreign  body  of  considerable  size  can 
be  felt  in  the  bladder  in  case  the  abdominal  walls  are  not  too  rigid. 
As  a  means  of  detecting  stone  in  the  bladder  of  women,  the  biman- 
ual touch  is  the  easiest,  safest,  and  surest  of  all  methods  of  explora- 
tion.    The  presence  of  neoplasms  can  be  discovered  in  this  way, 

743 


7U 


DISEASES  OF  WOMEN. 


although  their  composition  can  not  be  clearly  made  out.  In  some 
cases  it  is  necessarj'^  to  give  an  angesthetic  to  relax  the  parts  before 
a  satisfactory  bimanual  examination  can  be  made.  There  are  many 
advantages  gained  in  anaesthetizing  the  patient  while  making  a^ 
bimanual  examination,  but  some  of  the  most  important  signs  may 
be  lost  by  the  unconsciousness  of  the  patient,  such,  for  instance,  as 
the  location  of  tenderness.  On  that  account  I  prefer  in  critical 
cases  to  make  an  examination  both  without  and  with  anaesthesia. 
It  is  also  well,  when  the  object  is  to  search  for  foreign  bodies,  like 
stone  or  tumors  of  any  kind,  to  have  a  few  ounces  of  urine  in  the 
bladder,  unless  that  much  gives  the  patient  pain.  The  longer  I 
practice  the  more  I  depend  upon  this  method  of  examination. 

Another  method  of  examination  is  by  means  of  the  endoscope. 
For  this  purpose  I  devised  and  have  employed  for  years  an  endo- 
scope   which     has 
Fig.  250.  proved     of     great 

service.  This  in- 
strument is  com- 
posed of  three 
parts.  A  glass 
tube  (a,  Fig.  251) 
is  shaped  like  the 
ordinary  test  tube 
used  by  chemists, 
except  that  the 
mouth  is  a  little 
more  flaring.  The 
second  part  (J,  Fig.  251)  is  composed  of  two  pieces — a  mirror  and 
its  holder.  A  piece  of  very  thin  silver  plate  is  made  to  fit  nearly 
the  whole  length  of  the  inside  of  the  glass  tube,  and  about  one  third 
of  its  circumference.  To  the  end  of  this  arrangement  the  mirror  is 
attached  at  an  angle  of  aljout  100°.  At  the  other  end  a  delicate 
handle  projects  at  an  obtuse  angle.  This  part  of  the  instrument 
looks  like  a  section  of  a  tube  that  has  been  divided  into  three  equal 
parts  by  longitudinal  section,  with  a  mirror  attached  at  one  end  and 
a  handle  at  the  other.  This  piece  is  made  perfectly  black  on  the 
inside,  and  answers  two  purposes — it  holds  the  mirror,  and,  when 
placed  in  position  for  use,  darkens  one  side  of  the  glass  tube. 

It  will  be  seen  that  the  mirror  can  be  moved  forward  or  back- 
ward, and  turned  around  ;  so  that  when  the  tube  is  introduced  into 
the  urethra  or  l)ladder  the  exposed  internal  surfaces  can  be  brought 
into  view  by  moving  the  mirror  while  the  tube  remains  stationary. 


Figs.  250-252. — Skene's  endoscope. 


METHODS   OF  EXPLORATION. 


Y45 


Fig.  250  shows  the  glass  tube  placed  inside  of  a  fenestrated  hard- 
rubber  speculum,  and  Fig.  252  shows  the  glass  tube  inside  of  a 
speculum  that  is  open  and  beveled  at  the  end.  These  specula  are 
used  in  making  applications  to  the  urethra  and  bladder,  as  will  be 
described  hereafter. 

The  method  of  using  this  instrument  is  as  follows :  The  tube, 
with  the  mirror  inside,  is  introduced  into  the  urethra,  and  bladder 


Fig.  253. — Urethroscope  with  electric  light. 

also,  if  an  examination  of  the  lower  portion  of  the  latter  be  desired. 
Formerly  I  used  a  concave  mirror  to  throw  in  the  gas  or  electric 
light,  but  now  I  use  the  following  improved  urethroscope  with  elec- 
tric light :  The  instrument  consists  of  a  chamber  of  convenient  size, 
which  has  a  second  chamber  or  housing  built  upon  its  center.  The 
upper  or  vertical  chamber  contains  an  electric  lamp.  The  rays  of 
light  are  thrown  upon  a  mirror,  which  is  placed  in  an  oblique  posi- 
tion immediately  below  the  lamp.  The  light  is  reflected  upon  the 
mirror  to  the  front  of  the  instrument,  and  through  any  urethral 
tube  which  may  be  attached.  The  mirror  has  a  perforation  in  its 
center,  through  which  the  operator  sees  the  parts  to  be  examined. 
The  eyepiece  has  the  proper  magnifying  lenses,  and  is  adjustable,  so 
that  the  focus  can  be  changed  to  suit  tubes  of  various  lengths  (see 
Fig.  253).  The  complete  instrument,  as  illustrated,  has  three  sizes  of 
straight  urethral  tubes  and  a  Skene's  endoscopic  tube,  with  a  mirror 
on  the  distal  end  of  an  adjustable  stem.  This  enables  one  to  exam- 
ine the  entire  length  of  the  female  urethra  through  the  glass  tube, 
which  is  held  in  position  while  the  mirror  is  inserted  or  withdrawn. 


746  DISEASES  OF  WOMEN. 

The  color  of  the  mucous  membrane  lining  the  urethra  and  blad- 
der has  already  been  described  ;  but  it  must  be  borne  in  mind  that 
tlie  endoscope  modifies  the  color  to  some  extent.  This  is  especially 
so  when  examining  the  urethra.  If  a  large-sized  tube  is  used,  the 
parts  are  put  upon  the  stretch,  and  the  pressure  of  the  glass  on  the 
mucous  membrane  interrupts  the  capillary  circulation  to  some  ex- 
tent, and  renders  the  color  as  seen  in  the  mirror  a  pale  pinkish 
white.  This,  when  understood,  does  not  interfere  with  the  exami- 
nation, as  it  only  tends  to  make  the  contrast  between  the  normal  and 
the  diseased  tissues  more  marked.  The  only  condition  where  the 
endoscope  might  lead  to  error  is  in  acute  general  congestion  of  the 
urethra.  The  pressure  of  the  instrument  causes  the  congestion  to 
disappear  in  part,  and  gives  the  idea  that  there  is  less  hyperemia 
than  there  really  is.  In  such  cases  I  use  the  speculum  or  the  ordi- 
nary endoscope  (Fig.  252),  and  thereby  remove  all  possibility  of 
error. 

By  a  little  practice  in  managing  the  light,  sufficient  dexterity  to 
examine  the  urethra  and  neck  of  the  bladder  thoroughly  and  satis- 
factorily can  soon  be  acquired. 

Cystoscopy. — The  cystoscope  of  Nitze  and  Leiter  is  the  instrument 
usually  employed  for  thoroughly  investigating  the  bladder.  Bruck, 
of  Breslau,  first  discovered  the  principles  of  the  instrument,  and 
Nitze  and  Leiter  perfected  it. 

The  cystoscope  (Fig.  254)  consists  of  a  silver  tube  of  the  shape 
of  a  catheter,  in  the  short  beak  of  which  a  platinum  wire  is  fastened. 

-  Wall  of  the  bladder. 


Platinum. 

Prism. 


Telescope. 
Fio.  254. — Cystoscope. 


V 
Water-pipes 


The  latter  is  made  incandescent  by  means  of  an  electric  current  which 
passes  through  it,  and  then  darts  its  rays  upon  the  wall  of  the  blad- 
der through  an  oval  window  in  the  concavity  of  the  beak,  covered 
with  transparent  quartz.  To  convey  the  current  of  electricity  to 
the  platinum,  an  insulated  wire  runs  through  the  whole  length  of  the 


METHODS  OF  EXPLORATION.  747 

shank ;  the  metal  of  the  tube  forms  the  connection  with  the  oppo- 
site pole.  No  cold-water  current  is  needed.  According  to  Nitze's 
design,  a  telescope  is  introduced  into  the  shank  of  the  cystoscopy 
It  enlarges  and  magnifies  the  spot  coming  into  sight.  Without  this 
telescope  we  should  not  see  much  more  at  the  time  than  a  spot  about 
the  size  of  a  pea  ;  with  it  we  are  enabled  to  inspect  a  portion  as  large 
as  a  silver  dollar,  and  even  more. 

At  the  junction  of  beak  and  shank,  corresponding  to  the  con- 
cave side,  a  rectangular  prism  is  cemented  in,  the  hypotenuse-plane 
of  which  acts  as  a  mirror  on  account  of  the  total  reflection  of  the 
rays.  Thus  a  diminished,  inverted  real  picture  arises  in  the  shank 
of  that  wall  of  the  bladder  which  is  situated  at  a  right  angle  to  the 
longitudinal  axis  of  the  instrument,  and  opposite  the  prism.  It  is 
again  inverted  by  means  of  the  lenses  of  the  telescope,  and  thrown 
to  the  outer  end  of  it,  where  the  examining  person  looks  at  the  now 
upright  picture  through  the  magnifying  ocular  of  the  telescope. 

If  the  fundus  of  the  bladder  is  to  be  inspected  with  this  instru- 
ment it  must  be  turned  180°,  and  its  handle  deeply  depressed  be- 
tween the  thighs  of  the  patient,  the  latter  being  in  the  recumbent 
(lithotomy)  position — the  best  for  examination  with  the  cystoscope. 

This  manipulation  may  sometimes  be  very  painful.  To  avoid 
this,  a  second  instrument  (Fig.  255j  is  made  with  the  window  for 


Telescope. 

Water-pipes. 


Wall  of  the  bladder. 
Fig.  255. 


the  incandescent  platinum  on  the  convex  side  of  the  beak.  There 
is  another  window  at  the  end  of  the  straight  tube  through  which 
the  observer  looks  with  the  telescope.     Of  course  there  is  no  prism. 

Leiter's  cystoscope  shows  the  old  pattern  with  the  improvements 
mentioned.  A  key  near  the  handle  can  be  made  to  make  or  break 
the  current  by  turning  to  the  right  or  left  upon  or  from  an  ivory 
plate.  The  shank  of  the  instrument  is  somewhat  short ;  its  tele- 
scope diminishes  the  part  in  view  a  trifle. 

Before  using  the  cystoscope  the  beak  should  be  put  in  water,  and 
the  light  tested  to  see  that  it  is  in  working  order.     Glycerin  should 


748  DISEASES  OF   WOMEN. 

be  used  to  lubricate  the  instrument.  The  bladder  must  be  washed,, 
provided  the  urine  is  bloody  or  cloudy  with  mucus,  and  then  be 
partially  distended  with  from  five  to  six  ounces  of  clear  water.  If 
the  urine  is  quite  clear  no  preliminary  washing  is  necessary. 

A  few  years  ago  Howard  A.  Kelly  gave  to  the  profession  his 
method  or  system  of  investigating  the  diseases  of  the  urinary  organs 
of  women,  which  I  consider  a  most  valuable  contribution  to  this 


Fig.  256. — Leiter  cystoscope. 

branch  of  surgery,  especially  in  the  management  of  the  class  of 
cases  now  to  be  considered.  The  original  element  in  Kelly's  method 
is  placing  the  patient  in  the  Trendelenburg  or  knee-chest  position 
while  using  the  endoscope  for  the  purpose  of  making  a  diagnosis, 
and  in  catheterizing  the  ureters,  and  for  direct  treatment  of  the 
urethra  and  bladder.  His  modification  of  the  endoscope  and  his 
way  of  using  it  are  no  doubt  improvements  of  great  value,  but 
are  not  likely  to  supplant  other  ways  of  exploration  for  diagnostic 
purposes. 

For  inspecting  the  bladder  and  urethra  the  older  ways  are  pref- 
erable, and  in  catheterizing  the  ureters  the  newer  method  of  doing 
so,  with  the  aid  of  the  cystoscope,  is  easier  for  some  of  us.  The 
objections  to  the  general  employment  of  Kelly's  method  of  exami- 
nation are  that  rapid  and  extensive  dilatation  of  the  urethra  are  neces- 
sary, and  that  it  requires  the  patient  to  be  anaesthetized.  Taken 
altogether,  it  makes  the  examination  really  a  formidable  operation. 
Dilatation  of  the  normal  urethra  is  an  outrage  that  often  does  dam- 
age  that  is  not  easily  relieved.  Since  the  discovery  of  the  germ 
causation  of  surgical  diseases  practitioners  have  felt  safe  in  being 
surgically  clean  in  their  work,  and  have  become  unmindful  of  the 
fact  that  injuries  such  as  abrasions,  contusions,  or  lacerations  of  tlie 
mucous  membrane  of  the  urinary  tract  often  cause  serious  troul)le. 
There  is  no  reliable  tendency  to  repair  injuries  of  tissues  that  are 
continually  bathed  with  urine,  and  when  the  urine  is  abnormal  very 
serious  results  may  follow  the  slightest  traumatism.     In  view  of 


METHODS   OP  EXPLORATION.  749 

these  facts,  and  recalling  the  results  of  the  practice  of  a  few  years 
agfo,  when  dilatation  of  the  urethra  was  in  fashion  for  diacrnostic 
purposes  and  for  the  relief  of  certain  affections,  one  shrinks  from 
the  risk  of  adding  to  the  list  of  cases  of  incontinence  and  chronic 
urethritis.  In  my  hands  some  slight  disturbance  has  often  followed 
the  use  of  the  cystoscope  of  Xitze  and  Leiter,  which  raised  the  same 
objection  to  its  use  as  to  Kelly's  instrument.  Owing  to  the  sharp 
flexion  at  the  point  of  the  instrument  it  could  not  be  passed  through 
the  ordinary-sized  urethra  without  causing  pain  and  doing  some 
little  damage.  These  difiiculties  were  all  overcome  by  having  a 
cystoscope  made  straight.  This  improvement  has  been  a  great  help 
to  me.  With  this  instrument  the  female  bladder  can  be  explored 
without  pain  or  injury,  excepting  when  its  walls  are  thickened  and 
contracted  so  that  it  will  not  hold  the  required  amount  of  water. 
In  such  cases  Kelly's  method  meets  the  requii-ements  most  admi- 
rably. At  one  time  I  was  unable  to  use  the  cystoscope  when  there 
was  hgemorrhage  from  vascular  neoplasms  or  ulceration.  Then  I 
looked  to  Kelly's  method  for  aid,  but  I  found  it  was  not  satisfactory, 
because  the  blood  obscured  the  field  of  vision  and  one  could  not  see 
what  it  came  from.  This  obstacle  can  be  overcome  by  prolonged 
washing  of  the  bladder  with  a  solution  of  acetic  acid,  which  controls 
the  bleeding,  so  that  there  has  been  no  trouble  in  this  respect  since 
adopting  this  plan. 

In  cystitis  and  urethritis  together  the  use  of  the  endoscope  and 
cystoscope  is  painful,  but  the  application  of  cocaine  overcomes  that 
difficulty.  Instilling  into  the  urethra  a  two-per-cent  solution  of  that 
local  anaesthetic  renders  the  parts  tolerant  to  the  use  of  the  instru- 
ments in  most  cases.  To  obtain  the  desired  ansesthesia,  a  mild  solu- 
tion should  be  repeated  as  many  times  as  is  necessary.  That  is  safer 
and  more  efficient  than  one  application  of  a  strong  solution. 

I  can  safely  say  that  with  the  straight  cystoscope  the  bladder  can 
be  examined  with  as  much  facility  as  one  can  make  a  speculum  ex- 
amination of  the  uterus  and  vagina,  and  with  no  moi"e  distress  to  the 
patient.  And  I  am  sure  that  it  is  not  claiming  too  much  to  say  that 
all  structural  changes,  gross  and  minute,  can  be  seen  and  studied  far 
more  clearly  than  by  any  other  method  of  inspection  yet  discovered. 
For  examination  of  the  urethra  I  still  use  my  old  endoscope,  per- 
haps because  I  am  used  to  it,  but  I  must  acknowledge  that  the  older 
endoscope,  improved  in  mechanism  by  Kelly,  is  more  easily  em- 
ployed and  satisfactory^  to  the  majority  of  surgeons. 

W.  Donald  Napier  has  invented  a  probe  that  is  of  use  in  detect- 
ing foreign  bodies  in  the  bladder.     No  dilatation  of  the  urethra  is 


750 


DISEASES  OF  WOMEN. 


needed  for  its  use.  It  consists  of  a  beaked  sound,  the  vesical  end  of 
which  is  covered  with  pure  metallic  lead.  This,  having  been  care- 
fully polished  with  soft  leather,  is  dipped  into  a  one-per-cent  solu- 
tion of  nitrate  of  silver,  which  gives  it  a  beautiful  black  coating. 


Fig.  257. — Skene's  nioilifiuation  of  the  cystoscope  ;  half  actual  size. 

Before  use  it  should  be  carefully  examined  with 
a  lens  to  see  that  its  surface  is  perfect.  When 
introduced  into  the  bladder,  if  any  hard  body 
be  present,  such  as  a  calculus,  against  which  it 
strikes,  an  obvious  impression  is  made  upon  the 
polished  surface. 

Exploration  of  the  bladder  by  dilatation  of  the  urethra  is  a  most 
valuable  means  of  diagnosis.  It  may  be  employed  in  various  de- 
grees. The  urethra  may  be  enlarged  only  sufficiently  to  admit  a 
fair-sized  endoscopic  tube,  or  it  may  be  dilated  sufficiently  to  admit 
the  finger.     I  will  first  give  the  methods  that  are  commonly  in  use, 


Fig.  258 


i?<SH) 


and  then  explain  the  plan  I  usually  adopt.  Although 
there  are  records  of  bloodless  dilatation  of  the  ure- 
thra as  far  back  as  1502  (Benivienni),  1506  (Marcus 
Sanctus),  and  1501  (Franco),  up  to  a  late  date  the 
operation  was  not  a  common  one.  Franco  used  an 
instrument  of  his  own  for  effecting  dilatation.  In 
the  early  part  of  the  present  century  dilatation  by  means  of  the 
compressed  sponge  and  Weisse's  metal  dilator  was  somewhat  used, 
but  more  for  the  extraction  of  calculi  and  foreign  bodies  than  for 
purposes  of  diagnosis. 

To  Simon,  however,  belongs  the  honor  of  improving  the  means 
employed  and  introducing  the  subject  to  the  profession.  Ilis  method 
is  this  :  lie  makes  a  single  incision  superiorly,  or  two  slight  lateral 
ones,  in  the  wall  of  the  meatus,  about  one  tenth  of  an  inch  in  depth. 
He  also  snips  the  urethro-vaginal  septum  to  the  depth  of  about  one 


METHODS  OP  EXPLORATION. 


tol 


fifth  of  an  inch.  This  is  done  to  relax  and  prevent  irregular  tearing 
of  the  meatal  portion  of  the  urethra,  wliich  is  the  most  rigid  and 
nndilatable  part  of  the  canal. 

ile  next  introduces  a  hard-rubber  speculum,  shaped  somewhat 
like  a  cone,  the  cut  end  of  which  is  protected  by  a  rounded  piece  of 
wood  within.  His  largest  speculum  has  a  diameter  of  nearly  one 
inch,  his  smallest  about  one  third  of  an  inch.  After  the  introduc- 
tion of  the  largest  one  the  linger  can  be  readily  passed  into  the 
bladder  and  the  whole  of  its  interior  explored,  save  the  antero-lat- 
eral  portion,  which  is  high  up  and  difficult  to  reach.  The  narrowest 
urethra  may  in  this  manner  be  sufficiently  dilated  in  from  five  to  ten 
minutes. 

Simon  found  that,  without  any  bad  results  following,  an  adult 
woman  could  bear  the  introduction  of  a  speculum  having  a  circum- 
ference of  two  and  a  half  inches,  and,  when  the  necessity  for  marked 
dilatation  was  urgent  and  possibly  resulting  incontinence  of  com- 
paratively little  importance,  a  cone  having  a  cii'cumference  as  high 
as  two  and  eight  tenths  inches  might  be  employed. 

In  girls,  specula  having  a  circumference  of  from  1*88  inch  to 
2*52  inches  may  be  used.  For  most  diagnostic  and  therapeutic  pur- 
poses, instruments  not  large  enough  to  produce  incontinence  are 
usually  sufficient. 

Winckel  has  used  Simon's  method  seven  times,  and  has  had  ex- 
cellent results ;  and  he  says  that,  although  the  incisions  made  at  the 
meatus  are  sometimes  opened  still  farther,  and  that  a  fresh  one  may 
appear  under  the  clitoris, 
it  is  of  little  moment,  as 
the  presence  of  the  dilator 
stops  all  haemorrhage,  and 
the  incisions  heal  readily. 
In  none  of  Winckel's  cases, 
although  he  watched  them 
for  weeks,  was  there  any 
incontinence.      Heath,   in 

digital  dilatation,  found  usually  a  tearing  of  the  mucous  membrane 
under  the  pubic  arch,  and  incontinence  was  generally  present  for  at 
least  twenty-four  hours. 

Instead  of  incising  the  meatus,  I  generally  dilate  it  slowly,  using 
for  this  purpose  the  bivalve  urethral  speculum  (Fig.  259).  "When 
used  as  a  dilator,  I  cover  the  blades  with  a  piece  of  soft-rubber 
tubing. 

Notwithstanding  the  testimony  to  the  contrary,  I  am  sure  that 


Fig.  259. — Bivalve  urethral  speculum  (Skene). 


752  DISEASES  OF  WOMEN. 

dilatation  of  the  urethra  to  any  great  extent  is  dangerous.  There  is 
a  liability  to  lacerate  the  urethra  and  cause  incontinence,  which  can 
not  be  easily  cured.  Great  care  should  therefore  be  exercised  in 
dilatation,  and  it  should  not  be  resorted  to  at  all  unless  there  is 
some  marked  indication  for  it. 

In  cases  where  extreme  dilatation  of  the  urethra  does  not  prove 
sufficient  for  the  desired  end,  the  method  of  opening  into  the  blad- 
der through  the  vaginal  wall,  as  recommended  by  Simon,  may  be 
tried.  He  makes  an  incision  from  right  to  left  into  the  anterior 
vaginal  wall  just  in  front  of  the  os  uteri.  From  the  center  of  this 
incision  another  is  carried  forward  about  one  inch  in  length  in  the 
line  of  the  urethra,  thus  forming  a  T  incision.  Fine  tenacula  are 
then  fastened  into  the  bladder-wall  through  the  incision,  and,  with 
one  hand  pressing  the  abdomen,  and  by  traction  on  the  tenacula,  the 
bladder  is  pulled  down  through  the  incision  and  opened.  After  all 
necessary  procedures  are  completed,  the  edges  should  be  carefully 
secured  by  sutures,  and  the  parts  will  heal  kindly.  The  bladder- 
walls  coapt  readily  and  accurately. 

It  will  be  understood  that  this  important  operation  is  only  to  be 
performed  for  the  purpose  of  detecting  and  removing  foreign  bodies 
and  abnormal  growths  from  the  bladder,  and  possibly  to  close  vesico- 
intestinal fistulas. 

Rapid  dilatation  of  the  urethra  is  chiefly  useful  for  the  purpose 
of  allowing  the  extraction  of  foreign  bodies  and  moderate-sized  cal- 
culi, for  cauterizing  the  mucous  membrane,  for  opening  haemato- 
celes  (Spiegelberg),  for  allowing  the  introduction  of  endoscopic 
tubes  of  large  size  in  diagnosticating  cj^stitis,  calculi  (vesical  and 
ureteral),  ulceration,  vesico-intestinal  fistula,  polypi,  and  papilloma, 
and  for  the  local  treatment  of  these. 

Incision  into  the  bladder,  on  the  other  hand,  is  useful  in  cases 
where  calculi  or  other  bodies  are  too  large  for  safe  removal  by  the 
urethra,  the  removal  of  tumors  situated  high  up  anteriorly  or  antero- 
laterally,  in  operations  of  various  kinds  where  the  urethra  precludes 
free  movement  and  good  illumination,  as  in  sewing  up  large  vesico- 
intestinal fistulte.  I  may  observe,  in  passing,  that,  in  performing 
operations  through  the  incision,  artificial  light  might  be  thrown  into 
the  bladder  by  means  of  a  small  curved  endoscopic  tube  and  concave 
mirror  in  the  urethra. 

In  cases  of  cystitis  and  vesical  ulceration  this  operation  has  been 
performed  by  Sims,  Emmet,  Bozeman,  Simpson,  Ilegar,  and  Simon, 
to  prevent  the  stagnation  and  decomposition  of  urine  in  the  diseased 
organ. 


METHODS  OF  EXPLORATION.  753 

Catlieterization  of  the  ureters  has  been  performed  by  Simon  and 
Wincke],  but  as  it  is  ditHcult,  not  without  danger,  and  of  Uttle  prac- 
tical value,  I  sliall  not  dwell  upon  it  here. 

In  connection  with  the  subject  of  physical  exploration,  I  2;ive 
here  a  list  of  the  various  instruments  that  I  find  of  use  in  examin- 
ing and  operating  upon  the  bladder  and  urethra.  They  are  as  fol- 
lows : 

Two  Skene's  Sims's  specula. 

One  Folsom's  speculum  (modification). 

One  Skene's  refiux  catheter  for  urethra. 

Two  silver  probes. 

One  sponge-holder  (steel). 

One  knife. 

One  Blake's  polypus-snare  (ear). 

One  Allen's  polypus-forceps  (ear). 

Two  glass  pipettes,  six  inches  long. 

Two  head-mirrors  on  same  strap,  three  and  a  half  inches  and 
one  and  a  half  inch. 

Skene's  bivalve  urethral  specula. 

Ordinary  urethral  endoscopes,  modified  by  Skene. 

Two  rectal  endoscopes  (long  and  short),  with  fenestrated  rubber 
specula. 

Three  urethral  endoscopes  (Nos.  13, 15, 17,  American),  with  bev- 
eled rubber  specula. 

Two  beveled  urethral  endoscopes  (Nos.  19,  21,  American),  with 
fenestrated  rubber  specula. 

One  brush  for  cleaning  endoscopes. 

Having  described  the  important  methods  to  be  employed  in 
physical  exploration  of  the  bladder,  I  now  pass  to  a  consideration 
of  the  organic  diseases  of  the  bladder  and  urethra. 


49 


CHAPTEE  XLIL 

ORGANIC   DISEASES    OF   THE   BLADDER. 

HAVESfG  treated  of  the  methods  of  physical  exploration  of  the 
bladder  and  urethra,  I  now  invite  attention  to  the  or;^anic  diseases 
of  these  organs,  and  shall  first  describe  those  which  affect  the  blad- 
der.    These  may  conveniently  be  divided  into  three  classes : 

I,  Inflammatory ;  II.  Xon-inflammatory ;  and  III.  Neoplasms, 
hyperplasia,  and  atrophy. 

I,  Injlaininatioii  of  the  lladder^  or'  cystitis  : 

Under  this  head  I  shall  include  all  forms  of  deranged  nutrition 
which  produce  disorders  of  function,  temporary  or  permanent  lesions 
of  structure,  and  the  morbid  material  known  as  the  "  products  of  in- 
flammation." 

Well-defined  typical  inflammation  presents  during  its  course  cer- 
tain peculiarities  which  are  characteristic  of  the  affection,  and  with- 
out the  existence  of  which  the  disorder  can  not  be  called  true  in- 
flammation. Inflammation,  however,  varies  in  character  with  the 
tissue  or  organ  involved  and  the  extent  or  intensity  of  the  diseaso ; 
and,  while  there  is  really  but  one  process  of  inflammation,  as  that 
process  is  often  interrupted,  prolonged,  or  modified  in  various  ways, 
its  products  must  necessarily  vary  greatly. 

Its  divers  grades  or  forms  are  distinguished  as  acute,  chronic, 
catarrhal,  interstitial,  suppurative,  croupous,  diphtheritic,  and  gon- 
orrhaeal. 

Before  entering  upon  tlie  consideration  of  cystitis  in  its  many 
forms,  I  desire  to  speak  of  hyperemia  and  haemorrhage  of  the  blad- 
der. This  latter  affection  might  more  properly,  perhaps,  be  consid- 
ered under  another  head,  but  it  is  so  close!}'  connected  with  liyper- 
reniia  and  inflammation  that  I  prefer  to  treat  it  here. 

Hypersemia. — In  all  cases  the  first  perceptible  departure  from  the 
normal  is  a  derangement  of  circulation.  IIyper<Tmia  of  the  mucous 
membrane  is  observed,  and  with  it  disorders  of  innervation,  as  is  evi- 
denced by  derangement  of  function  and  sensation, 

754 


ORGANIC  DISEASES   OP  THE  BLADDER.  755 

In  liypersemia  of  the  mucous  nieaibrane  of  the  bladder  the  blood- 
vessels are  distended,  and,  becoming  prominent  and  apparently  more 
numerous,  give  to  it  a  bright-red  color.  The  arteries  are  the  iirst 
to  be  aflt'ected.  If  the  hypersemia  is  not  marked,  or  is  produced  bj 
some  transient  cause  and  not  aggravated,  it  may  pass  off  in  a  short 
time,  and  leave  the  membrane  in  its  normal  condition.  If  it  is  of  a 
high  grade,  however,  rupture  of  some  of  the  vessels  may  occur,  the 
haemorrhage  taking  place  either  on  the  free  surface  of  the  membrane 
or  beneath  its  epithelial  layer.  Should  this  condition  continue,  the 
hypersemia  which  began  in  the  arteries  extends  to  the  venous  side  of 
the  circulation,  and  the  vessels  become  more  prominently  and  uni- 
formly distended.  The  congestion  may  also  begin  on  the  venous 
and  extend  to  the  arterial  side,  as  in  sudden  interference  with  portal 
circulation.     As  a  rule,  however,  it  begins  in  the  arteries. 

A  clear  distinction  must  be  made  between  the  acute  congestion 
of  which  I  am  now  speaking,  and  which  is  chiefly  contined  to  the 
smaller  vessels,  and  passive  congestion  with  a  varicose  or  hgemor- 
rhoidal  condition  of  the  veins  about  the  neck  of  the  bladder.  This 
hsemorrhoidal  condition  I  will  speak  of  later. 

Symptomatology. — The  symptoms  of  acute  congestion  of  the 
bladder,  as  a  rule,  occur  suddenly.  Frequent  but  painless  m-ination 
is  the  principal  symptom.  There  is  often  a  sense  of  heat  and  heavi- 
ness in  the  region  of  the  bladder,  which  is  greatly  aggravated  by 
standing  or  walking.  When  the  urethra  is  involved,  the  patient 
complains  that  the  urine  "scalds''  her. 

The  general  system  is  not  disturbed — i.  e.,  the  pulse  and  tempera- 
ture remain  noraiaL  The  physical  signs  are  mostly  negative.  The 
composition  of  the  urine  is  unchanged,  save  that  there  may  l)e  an 
excess  of  mucus  and  a  few  blood-globules  present.  There  may  be 
some  tenderness  on  pressure  over  the  bladder.  The  endoscope  (when 
there  is  an  opportunity  to  use  it,  which  is  very  rare  in  this  trouble) 
shows  an  increased  redness  of  the  mucous  membrane,  with  occasion- 
ally an  excess  of  mucus  on  its  surface. 

Diagnosis. — The  diagnosis  has  to  be  made  by  exclusion,  the  nat- 
ural history  of  the  affection  having  in  it  nothing  pathognomonic. 
It  is  liable  to  be  confounded  with  sympathetic  or  other  functional 
derangement  of  the  bladder,  caused  by  sudden  dislocations  of  the 
uterus  or  by  pelvic  inflammation,  such  as  pelvic  peritonitis  and  its 
results.  The  former  can  be  excluded  by  an  examination  of  the  pel- 
vic organs,  and  the  latter  by  the  constitutional  symptoms  of  inflam- 
mation and  the  signs  of  such  pelvic  disease. 

Causes. — The  causes  of  hypersemia  of  the  bladder  are  exposure 


756  DISEASES  OF  WOMEN. 

to  cold  (especially  during  the  menstrual  period),  wetting  the  feet, 
overtaxation  in  walking  or  using  the  sewing-machine,  excessive  vene- 
real indulgence,  constij)ation  of  the  bowels  from  torpor  of  the  portal 
circulation,  the  excessive  use  of  stimulants,  and  the  use  of  improper 
articles  of  food. 

Treatment. — The  treatment  should  be  directed  to  equalizing  the 
circulation.  Diaphoretics,  warm,  stimulating  foot  baths,  hot  applica- 
tions over  the  epigastrium,  and,  above  all,  rest  in  the  recumbent 
position.  If  the  bowels  are  confined,  tbey  should  be  emptied  by 
saline  laxatives.  When  there  is  much  irritation  of  the  bladder,  caus- 
ing frequent  urination  and  vesical  tenesmus,  pulv.  doveri  with  cam- 
phor should  be  given,  or  suppositories  of  belladonna  and  morphine 
introduced  into  the  vagina.  Under  this  treatment  the  trouble  will 
usually  pass  off  in  a  short  time.  It  may,  however,  go  on  to  the  de- 
velopment of  cystitis. 

Occasionally  bleeding  occurs  in  active  or  acute  congestion  of  the 
bladder,  and  that  leads  me  to  speak  of  hemorrhage  from  the 
bladder. 

Haemorrhage  from  the  Bladder. — Haemorrhage  from  the  bladder, 
or  (if  I  may  be  allowed  to  coin  a  word)  cystorrhagia,  is  usually  due 
to  some  important  disease  of  the  bladder,  and  is,  therefore,  rather  a 
symptom  than  a  disease.  For  this  reason  I  will  at  present  confine 
my  remarks  to  hsemorrhage  when  caused  by  acute  congestion,  which 
I  have  just  considered,  or  to  varicose  veins  of  the  bladder. 

The  bleeding  may  take  place  from  the  free  surface  of  the  mucous 
memljrane,  and  mingle  at  once  with  the  urine  or  coagulate  in  the 
bladder.  It  may  also  take  place  beneath  the  surface  of  the  mucous 
membrane,  and  form  ecchymoses,  like  the  spots  seen  beneath  the 
skin  in  purpura.  We  may  also  have  a  condition  known  as  htemo- 
globinuria,  in  which  only  the  coloring  matter  of  the  blood  is  found 
in  the  urine  ;  in  such  a  case  we  should,  of  course,  find  no  blood-cor- 
puscles. 

The  quantity  of  blood  varies  greatly  in  different  diseases,  and  in 
the  same  disease  in  different  persons.  In  congestion  of  the  bladder 
blood-globules  will  often  be  found  in  the  urine  only  on  microscopic 
examination,  while  at  other  times  the  urine  will  have  the  appearance 
of  being  all  blood.  Again,  the  blood  may  coagulate,  and  be  passed 
in  clots,  or  the  coagula  may  remain  in  the  bladder,  finally  break 
down,  and  be  passed  as  a  chocolate-colored  or  blackish  matter. 

Symptomatology. — The  symptoms  of  haemorrhage  do  not  differ 
from  those  of  congestion  or  the  onset  of  cystitis,  except  when  small 
clots  form,  distending  the  urethra,  and  causing  pain  in  urinating.    It 


ORGANIC  DISEASES  OP  THE  BLADDER.  Y5Y 

is  very  rare  that  bleeding  from  these  causes  is  sufficient  to  prostrate 
the  patient. 

As  bleeding  may  take  place  at  any  point  in  the  urinary  tract,  it 
is  important  always  to  locate  the  hseraorrhage.  When  coming  from 
the  bladder  in  any  quantity,  it  is  usually  passed  in  small  clots,  and 
is  seldom  so  intimately  mixed  with  the  urine  as  when  it  comes  from, 
the  kidneys  or  ureters.  This  statement  is  not  exact,  and  at  best 
gives  but  a  probable  idea  of  the  true  facts.  To  complete  the  diag- 
nosis, we  nmst  resort  to  something  more  trustworthy.  Sir  Henry 
Thompson  gives  a  very  ingenious  method  for  determining  as  to 
whether  pus  found  in  the  urine  comes  from  the  kidneys  or  bladder, 
and  Van  Buren  and  Keyes  advise  the  same  plan  for  detecting  the 
source  of  haemorrhage. 

The  method  is  this :  "  A  soft  catheter  is  gently  introduced  first 
within  the  neck  of  the  bladder,  the  urine  drawn  off,  and  the  cavity 
washed  out  very  gently  with  tepid  water.  If  the  water  can  not  be 
made  to  flow  away  clear,  the  inference  is  that  the  blood  comes  from 
the  cavity  of  the  bladder.  If  it  will  flow  away  clear,  then  the  cath- 
eter is  closed  for  a  few  moments,  the  patient  being  at  rest,  and 
the  few  drachms  of  urine  which  collect  may  be  drawn  o£E  and  exam- 
ined. The  bladder  is  now  again  washed  out,  and  if,  after  a  single 
washing,  the  second  flow  of  injection  is  clear,  while  the  drachm  of 
urine  was  bloody,  the  inference  is  again  complete  that  the  blood 
comes  from  one  or  the  other  kidney." 

When  it  is  known  that  the  patient  has  had  no  kidney-disease, 
nor  symptoms  of  renal  calculi,  the  endoscope  may  be  employed,  and 
possibly  the  bleeding-point  found.  This  has  been  done  with  the 
instrument  which  I  have  described,  but  one  may  fail  to  find  it  if  it 
be  high  up  laterally  or  antero-laterally,  or  be  covered  by  a  fold  of 
the  mucous  membrane. 

Hsemorrhage  from  the  urethra  might  mislead,  but  is  easily  de- 
tected if  it  is  remembered  that  in  this  case  bleeding  occurs  between 
the  acts  as  well  as  during  micturition.  It  may  also  readily  be  dis- 
covered with  the  endoscope,  provided  the  tube  be  not  too  large. 

Causation. — The  causes  of  vesical  haemorrhage,  or  cystorrhagia, 
are  numerous.  Congestion,  varicose  veins,  villous  cancer,  lesions  of 
structure,  as  in  ulceration  and  sloughing  of  mucous  membrane  from 
injury  or  cystitis,  and  obstruction  to,  or  interference  with,  the  portal 
circulation.  This  may  possibly  explain  the  fact  that  haemorrhage 
occasionally  occurs  in  those  suffering  from  malaria.  Perhaps  the 
vesical  haemorrhage  occurring  in  the  intense  heat  of  summer  in  the 
tropics  may  be  thus  explained.     In  malaria  the  obstruction  to  the 


758  DISEASES  OF  WOMEN. 

circulation  through  the  portal  system,  acting  as  a  predisposing  cause, 
the  intense  congestion  of  ail  the  internal  organs  during  a  chill  or 
from  exposure  to  cold  would  certainly  tend  to  produce  cystorrliagia. 

In  purpura,  the  eniptive,  typhus,  and  typhoid  fevers,  bleeding 
from  the  bladder  may  occur ;  but,  as  it  is  there  secondary  to  the 
main  disease,  nothing  need  be  said  about  it  in  this  connection. 

The  most  marked  predisposing  cause  of  cystorrhagia  in  women 
is  a  tendency  to  the  hsemorrhagic  diathesis,  so  common  among  chlo- 
rotic  females. 

Treatment. — The  treatment  must  largely  depend  on  the  cause. 
In  all  cases  rest  in  the  recumbent  position  should  be  insisted  on.  A 
large  number  of  haemostatics  have  been  recommended,  and  some  of 
them,  such  as  aromatic  sulphuric  acid,  tannic  and  gallic  acids,  in 
moderate  doses,  are  doubtless  of  some  value.  I  have,  however,  de- 
pended chiefly  on  doses  of  opir>m  sufficiently  large  to  quiet  the  desire 
to  urinate,  and  alkaline  diluents  to  render  the  urine  non-irritant,  when 
it  was  found  to  be  excessively  acid. 

If  tho  bleeding-point  or  points  can  be  discovered  with  the  endo- 
scope, applications  of  acetic  acid,  persulphate  of  iron,  or  nitrate  of 
silver  may  be  made.  Great  care  must  be  taken  in  using  these  reme- 
dies, lest  inflammation  and  ulceration  of  the  bladder  result.  Nitrate 
of  silver  and  strong  acetic  acid  are  more  to  be  feared  than  the  others. 

When  the  liiiemorrhage  is  so  free  as  to  excite  fears  of  prostration, 
ice  may  be  employed.  Small  smooth  pieces  should  be  introduced 
into  the  vagina  at  regular  intervals  as  long  as  the  patient  can  com- 
fortably bear  it.     Ice  may  also  be  applied  to  the  hypogastrium. 

When  the  blood  coagulates  and  forms  a  large  clot  in  the  bladder, 
it  should  be  allowed  to  remain  until  it  breaks  down  and  comes  away 
of  itself.  The  experience  of  surgeons  is  that  there  is  much  more 
danger  in  attempting  to  remove  the  clot  than  in  letting  it  alone 
There  are  two  dangers  in  removing  coagula  from  the  bladder.  Ono 
is,  that  doing  so  will  almost  certainly  start  the  bleeding  again ;  and 
the  other  is  liability  to  injure  the  bladder,  and  cause  inflammation. 
Let  the  clots  take  care  of  themselves,  keeping  the  patient  quiet  and 
comfortable  (with  opium,  if  necessary)  until  the  coagula  are  disposed 
of.  Lime-water  has  been  recommended  as  a  solvent  of  blood-clots 
by  Dr.  J.  H.  Ledlin,  of  Pittsfield,  Illinois,  and,  in  the  case  reported 
by  him,  and  which  is  narrated  with  the  cases  of  haemorrhage  in  this 
chapter,  seems  to  have  acted  well. 

In  one  case  of  traumatic  vesical  ha3morrhage  that  came  under 
my  care,  a  large  clot  formed  in  the  bladder,  and  urination  was  com- 
pletely arrested.     I  was  unable  to  determine  wdiether  the  inability 


ORGANIC  DISEASES  OF   THE  BLADDER.  759 

to  urinate  was  due  to  the  presence  of  the  clot  or  to  loss  of  contractile 
power  of  the  vesical  walls  from  the  injury.  The  patient  suffered  so 
much,  however,  from  the  pain  caused  by  retention  that  I  was  obliged 
to  use  the  catheter.  I  employed  the  flexible  instrument  of  Jaques, 
and,  by  carefully  worming  it  in  past  the  clot,  I  succeeded  from  time 
to  time  in  drawing  off  enough  of  the  urine  and  broken-down  clot  to 
relieve  the  lady  until  she  was  able  to  reHeve  herself.  I  was  careful 
not  to  disturb  the  clot. 

Allusion  has  been  made  to  varicose  veins  of  the  bladder,  called 
by  some  haemorrhoids  of  the  bladder.  This  condition  is  chiefly 
found  in  pregnant  women,  especially  those  who  have  borne  several 
childi'eu.  The  cause  is  interruption  of  the  venous  circulation  Ijy 
pressure  of  the  gravid  uterus.  The  veins  of  the  anterior  vaginal 
wall,  introitus  vulvae,  and  labia,  will  often  be  found  in  the  same 
condition.     Occasionally  prolapsus  of  the  bladder  ^\dll  also  be  found. 

This  affection  gives  rise  to  those  symptoms  of  pelvic  distress  and 
frequent  urination  that  are  so  troublesome  in  some  pregnant  women. 
It  must  be  kept  in  mind,  however,  that  the  same  symptoms  may 
come  from  pressure  which  does  not  produce  varicose  veins. 

If  it  is  found  that  the  patient  feels  relieved  to  some  extent  in 
the  recumbent  position,  and  the  urine  is  normal,  this  trouble  may 
be  suspected,  and,  if  the  symptoms  are  sufficiently  urgent,  a  local 
examination  should  be  made,  which  wdll  reveal  a  varicose  condition 
of  the  vessels  of  the  urethra  and  vaginal  walls,  and  from  this  it  may 
be  inferred  that  the  same  condition  exists  in  the  bladder. 

If  the  diagnosis  is  still  doubtful,  the  endoscope  will  aid  in  settling 
the  question. 

This  affection  is  relieved  or  passes  off  altogether  after  confine- 
ment, and  the  best  that  can  be  done  usually  is  to  give  rest  and  try 
to  make  the  patient  comfortable  until  the  end  of  her  "  term." 

Should  the  trouble  continue  after  delivery,  especially  if  there  is 
cystocele  or  prolapsus  of  the  bladder,  much  good  may  be  done  by 
restoring  and  keeping  the  organ  in  place.  This  can  best  be  accom- 
plished by  using  the  cotton  pessary  or  a  roll  of  marine  lint  packed 
loosely  into  the  vagina,  like  a  tampon.  The  patient  can  be  instructed 
to  use  this  herself.  Attention  should  be  given  to  the  general  health, 
and  particularly  to  the  condition  of  the  bowels  and  portal  circulation. 
Rest  in  bed,  and  the  use  of  cool  water  as  a  vaginal  injection,  may 
also  be  of  use. 

Should  haemorrhage  occur  from  this  condition  of  the  veins,  it 
may  be  treated  as  described  in  the  discussion  of  that  subject. 


760  DISEASES  OF  WOMEN. 


ILLUSTRATIVE    CASES. 


Case  of  Haemorrhage  of  the  Bladder ;  Blood-clots  dissolved  by  Lime- 
water. — J.  II.  Ledlin,  M.  D.,  Pittsfield,  Illiuois,  in  a  letter  to  the 
"  Medical  Record,"  November  8, 1879,  says  :  I  have  a  patient,  a  man 
who  for  years  has  suffered  greatly  from  hgematuria.  The  blood 
comes  from  the  kidneys.  At  times  the  hsemorrhage  is  very  profuse, 
and  clots  the  bladder.  Heretofore  I  have  always  succeeded  in  wash- 
ing it  out  with  a  double  current  catheter.  Last  Saturday  I  was  called 
to  see  him.  He  had  lost  a  great  quantity  of  blood,  and  was  suffering 
very  much  from  vesical  tenesmus  ;  I  passed  my  catheter,  and  injected 
a  stream  of  water.  All  at  once  the  stream,  returning,  would  stop. 
By  withdrawing  the  instrument  I  could  start  it  again,  but  he  insisted 
there  was  a  foreign  body  in  there.  I  must  say  that  the  previous  day 
he  had  experienced  excruciating  pain  along  the  course  of  the  ureter; 
1  suspected  stone,  and  sounded  him,  but  could  not  discover  one ; 
still,  my  instrument  touched  something  ;  I  repeated  the  washing  out 
of  the  bladder  until  the  water  returned  colorless.  I  then  made  up 
my  mind  that  there  was  a  clot,  with  the  coloring  matter  washed  out, 
and,  recollecting  your  account  of  dissolving  the  false  membrane  with 
lime-water,  I  threw  in  one  half  j)int  of  lime-water,  allowing  it  to 
remain  half  an  hour.  When  it  passed  off  it  resembled  what  you 
describe  as  the  appearance  of  the  false  meml^rane  after  lying  in  lime- 
v/ater.  He  also  passed  a  large  piece  of  tibrin,  which  had  evidently 
been  acted  on  by  lime-water,  although  not  sufficiently  to  dissolve  it 
entirely.  Had  it  not  passed  away,  I  am  convinced  another  injection 
would  have  dissolved  it  entirely.  He  is  now  quite  comfortable,  all 
sense  of  a  foreign  l)ody  in  the  bladder  having  passed  away. 

Haemorrhage  from  the  Bladder  due  to  Malarial  Influence. — This 
patient  was  a  lady  of  twenty-one,  married  two  years,  never  pregnant, 
and  of  a  slightly  strumous  constitution.  For  several  days  she  had  to 
urinate  more  frequently  that  usual.  She  then  began  to  be  I'estless  at 
night.  These  symptoms  developed  into  well-marked  fever  in  the 
afternoon  and  first  part  of  the  night.  With  this  came  frequent  urin- 
ation, with  pain  and  hfemorrhage  from  the  bladder.  The  blood 
came  from  the  neck  of  the  bladder  evidently,  from  the  fact  that  it 
was  mixed  with  the  urine,  but  was  dark  in  color,  as  it  would  have 
been  if  from  the  kidneys.  There  was  no  blood  passed  after  the 
l)ladder  was  empty,  as  would  have  been  the  case  if  it  came  from  the 
urethra. 

The  temperature  was  103°  F.  in  the  evening ;  normal  in  the 
morning.     This  continued  for  two  weeks,  at  which  time  I  gave  qui- 


ORGANIC  DISEASES  OF  THE   BLADDER.  701 

nine,  gr.  x,  in  the  morning.  After  the  qninia,  tlie  fever  and  bleed- 
ing stopped,  and  did  not  return.  She  was  for  over  a  year  well,  then 
her  trouble  returned — that  is,  she  had  painful  urination  without  haam- 
orrhage.  I  found  the  cause  to  be  a  polyj^oid  growth,  which  looked 
like  a  wart,  in  the  anterior  wall  of  the  urethra  near  the  meatus.  I 
removed  it  by  snare,  with  the  result  of  relieving  her  completely. 


CYSTITIS. 

This  is  a  disease  that  is  much  more  common  among  women  than 
is  generally  supposed.  It  is  necessary,  therefore,  to  inquire  carefully 
into  the  etiology,  pathology,  and  therapeutics  of  this  affection,  which 
causes  great  suffering  on  the  part  of  the  patient,  and  taxes  the  high- 
est skill  of  the  ablest  surgeons. 

To  the  several  forms,  grades,  or  degrees  of  this  disease  various 
names  have  been  given,  such  as  acute,  subacute,  and  chronic  cystitis, 
cystitis  mucosa  (catarrh  of  the  bladder),  interstitial  cystitis,  peri-  and 
epi-cystitis,  croupous,  diphtheritic,  and  gonorrhoeal  cystitis.  This 
medley  of  names  should  not  be  allowed  to  lead  to  confusion,  but 
this  fact  should  be  firmly  fixed  in  tlie  mind,  that,  with  the  exception 
of  the  last  three  (the  etiology  and  pathology  of  whi'jh  are  somewhat 
different),  they  are  all  simply  steps  or  stages  in  one  general  process. 
Thus  a  patient  may  have  received  an  injury  of  the  bladder  by  the 
use  of  a  catheter,  causing  an  acute  cystitis.  This  may  end  in  con- 
valescence, or  merge  slowly  into  the  more  chronic  form,  having  very 
likely  as  an  intermediate  step  catarrhal  cystitis.  This,  too,  may  go 
on  to  recovery  ;  but,  if  the  process  extends,  and  its  severity  increases, 
ulceration  takes  place,  and  the  submucous  and  intermuscular  tissues 
become  involved,  producing  interstitial  cystitis.  If  the  inflammation 
extends  still  further,  and  involves  the  serous  coat  of  the  bladder, 
either  by  extension  or  ulceration,  with  or  without  perforation,  we 
shall  have  peri-  or  epi-cystitis.  In  this  example  I  hope  I  have  made 
clear  the  fact  that  names  are  only  given  to  denote  the  degree  of  in- 
tensity of  the  inflammatory  process,  and  the  character  and  extent  of 
the  tissue  involved. 

Inflammation  of  the  mucous  membrane  alone  is  by  far  the  most 
common  form,  and  hence,  in  using  the  term  cystitis,  reference  is 
usually  made  to  inflammation  of  that  membrane  only.  When  other 
tissues  are  involved,  or  the  character  of  the  disease  is  peculiar,  some 
qualifying  word  is  added  to  distinguish  it. 

Acute  inflammation  of  the  bladder,  other  than  that  due  to  local 
causes,  is  emphatically  denied  an  existence  by  many  authors.     The 


762  DISEASES  OF  WOMEN. 

statements  made  are  usually  too  broad  and  sweeping  to  be  sustained 
by  the  facts  observed  in  actual  practice.  I  am  inclined  to  believe 
that  cases  of  acute  cystitis  from  exposure  to  cold  and  wet  do  occur. 
It  must,  however,  be  admitted  that  such  cases  are  very  rare,  and 
some  that  have  been  considered  as  acute  idiopathic  cystitis  may  have 
been  but  a  development  of  acute  inflammatory  disease  upon  a  pre- 
existing abnormal  condition. 

It  is  also  possible  that  those  who  deny  the  existence  of  acute  idio- 
pathic cystitis  may  base  their  belief  upon  the  fact  that  in  what  is 
called  acute  inflammation  of  the  bladder  all  the  phenomena  of  well- 
defined  inflammation  are  not  present,  while  others  consider  hyper- 
semia  of  the  mucous  membrane  and  derangement  of  bladder  function 
all  that  is  necessary  to  constitute  cystitis.  Thus  the  apparently  dif- 
ferent opinions  that  exist  among  authors  upon  this  subject  may  arise 
from  conflicting  views  as  to  what  really  constitutes  inflammation. 

I  prefer  to  class  this  condition  (of  congestion,  hypersecretion  of 
mucus,  abnormal  exfoliation  of  epitlielium,  and  irritability)  among 
the  inflammatory  affections,  and  call  it  acute  cystitis.  Such  an  affec- 
tion as  this  is  met  with  in  every-day  practice,  and  I  know  of  no  bet- 
ter name  for  it. 

With  this  understanding,  then,  I  will  pass  to  a  discussion  of 
acute  cystitis. 

Pathology. — As  acute  cystitis  soon  terminates  in  resolution,  or 
merges  gradually  into  chronic  cystitis,  I  think  it  best  to  give  the 
pathology  of  both  diseases  at  once,  they  being,  as  I  have  already  said, 
simply  different  in  degree  of  intensity  and  duration. 

The  morbid  anatomy  of  cystitis  is  the  same  as  that  of  inflamma- 
tion of  mucous  membranes  in  other  parts  of  the  body.  In  the  more 
acute  forms  the  membrane  is  swollen  and  relaxed,  and  of  a  bright 
or  deep  red  color,  from  hypertemia.  The  surface  is  partially  or  en- 
tirely covered  with  a  thick,  tenacious  mucus.  There  is  exfoliation 
of  the  epithelium,  as  shown  by  the  partially  denuded  condition  of 
the  membrane,  especially  at  the  top  of  the  rug?B,  and  pus  and 
loose  cells  are  found  in  the  sulci  between  the  folds. 

In  some  instances,  especially  in  cases  of  acute  cystitis  caused  by 
extreme  overdistention  due  to  mechanical  or  other  retention,  tliere 
may  occur  a  throwing  off  of  the  whole  or  only  a  part  of  the  mucous 
membrane  of  the  bladder.  This  is  more  apt  to  occur  wlien  the  re- 
tention and  overdistention  are  caused  by  various  accidents  of  the 
puerperal  state  or  during  delivery.  That  the  separation  of  the 
nmcous  membrane  is  not  due  to  direct  injury  caused  by  the  child's 
head  or  instruments  carelessly  used,  but  to  the  effect  of  overdisten- 


ORGANIC  DISEASES  OF  THE   BLADDER,  Y63 

tion,  is  shown  by  tlie  fact  tliat  the  vesical  neck,  which  is  subject  to 
the  most  direct  injury,  seldom  shows  separation  of  its  mucous  mem- 
brane. That  injury  to  the  organ  may  predispose  to  separation,  or 
even  determine  it  when  abeady  predisposed  to  it  by  some  other 
cause,  there  can  be  no  doubt.  Most  of  these  cases  of  separation  of 
the  mucous  membrane  have  occurred  in  women,  and  almost  all  fol- 
lowed delivery.  The  bladder  which  has  participated  in  the  general 
congestion  of  the  pelvic  organs  incident  to  the  puerperal  state  is  in 
an  excellent  condition  to  allow  such  separation  to  take  place. 

The  manner  of  its  production  is  probably  as  follows :  A  woman 
at  full  term  is  delivered  after  a  long  and  tedious  labor,  with  or  with- 
out the  use  of  instruments,  of  a  healthy  child.     The  child's  head  or 
the  forceps  may  have  done  violence  to  the  urethral  mucous  mem- 
brane by  crowding  the  urethra  against  the  unyielding  puljic  bones. 
Swelling  of  the  mucous  membrane  results,  and  retention  of  urine 
(if  the  patient  be  not  relieved  by  the  catheter)  follows  and  persists 
for  a  varying  length  of  time.     The  doctor,  the  nurse,  and  the  pa- 
tient herself  are  often  led  to  believe,  from  the  constant  or  inter- 
mittent dribbling  of  urine,  that  there  is  an  irritable  condition  of 
that  organ,  with  frequent  urination.     The  truth  is,  that  this  drib- 
bling (stillicidium)  is  almost  a  certain  sign  of  an  overfilled  bladder, 
and  if  the  patient  be  not  relieved  the  distention  will  gradually  in- 
crease.    The  organ  having  reached  its  limit  of  distention,  or  being 
stretched  to  its  utmost,  tlie  pressure  within  is  so  great  as  to  cut  off 
the  supply  of  blood  to  the  submucous  tissue,  and  thus  to  the  mu- 
cous membrane  itself.     This  is  more  readily  accom]3lished,  as  the 
muscular  fibers  are  pulled  apart  and  the  mucous  membrane  thereby 
allowed  a  certain  amount  of  bulging,  by  which  its  blood-supply  is 
seriously  interfered   with.      If  the    distention  be   relieved   early 
enough;  nothing  worse  than  an  acute  cystitis  results ;  but  if  not  re- 
lieved, partial  or  total  death  of  the  membrane  occurs,  and  it  is 
sooner  or  later  thrown  off.     Although  death  of  the  membrane  may 
not  take  place  in  every  case,  or  in  one  half  of  the  cases  of  overdis- 
tention,  it  is  no  argument  against  this  method  of  its  production. 
Nor  yet  is  it  an  argument  in  favor  of  the  idea  that  it  is  caused  by 
instrumental  violence  to  the  body  as  well  as  the  neck  of  the  viscus ; 
for  that  the  latter  can  not  be  the  only  cause  may  be  seen  from  the 
fact  that  it  has  occurred  in  the  male  (Liston  per  Barnes).     It  is 
probable  that  there  are  several  causes,  and  that  these  may  work  to- 
gether to  produce  the  result.     From    the    uniform    exfoliation   it 
would  look,  however,  as  if  the  most  important  cause  was  a  uniform 
pressure  cutting  off  the  blood-supply,  and  thus  causing  death  of  the 


764  DISEASES  OF  WOMEN. 

part.  It  is  even  to  be  conceived  that  where  marked  injury  has  been 
done  the  membrane  by  overdistention  (though  not  sufficient  in  it- 
self to  cause  death),  too  rapid  rehef  of  retention  causing  congestion, 
irritation  by  catheter,  peculiar  systemic  conditions,  and  the  intense 
inflammation  which  follows  may  finish  the  work.  viz. :  fully  carry 
out  tlie  impression  already  made  by  the  overdistention. 

This  affection  is  not  a  common  one,  and  though  cases  may  sel- 
dom be  met  1  desire  to  lay  stress  upon  the  great  importance  of  pay- 
ing strict  and  individual  attention  to  the  condition  of  the  urinary 
organs  in  pregnant  and  parturient  women.  The  catheter  can  tell 
more  of  the  condition  of  the  patient's  bladder  in  such  cases  than  any 
nurse,  and  can  do  no  harm  whatever  when  a  soft  instrument  is  used 
with  care. 

Experiments  on  dogs  have  proved  that  the  detachment  of  the 
membrane  begins  at  that  part  of  the  bladder  just  opposite  the  vesi- 
cal neck.  At  this  point  the  membrane  bulges  out  with  a  collection 
of  blood  and  serum  beneath  it,  and  this  bulging  gradually  extends 
to  other  parts.  Meantime,  in  the  bladder,  the  mucus  poured  out 
to  shield  the  membrane  causes  the  urine  to  decompose,  and  incrusta- 
tions of  amorphous  and  triple  phosphates  are  found  on  the  surface 
of  the  exfoliated  membrane.  The  color  of  the  mucous  membrane  is 
usually  either  a  deep  red,  greenish  red,  or  black,  and  it  may  come  away 
either  in  pieces  or  as  a  whole.  In  some  cases  (Mr.  Wells's  second 
case,  Barnes)  part  of  the  muscular  as  well  as  the  mucous  tissue 
sloughed  off  and  came  away.  In  Mr.  Liston's  case  the  entire 
nnicous  membrane  came  away  through  a  supra-pubic  opening  made 
by  that  gentleman  to  relieve  retention.  This  occurred  in  the  case 
of  a  male  adult. 

Some  of  these  patients  have  recovered,  and  it  is  believed  by 
Schatz  that  the  reproduction  of  the  membrane  commences  at  that 
portion  of  it  always  left  at  the  vesical  neck. 

That  the  completion  of  the  sloughing  does  not  takes  place  until 
sometime  after  the  injury  is  done,  and  that  the  membrane  itself  may 
block  the  urethra  and  cause  further  retention,  is  illustrated  by  the 
following  case,  taken  from  Barnes's  able  lecture  in  the  "  Lancet," 
January  2,  1875.  The  case  was  under  the  care  of  Dr.  Wardell, 
at  the  Infirmary,  Tunbridge  Wells.  "  A  woman  was  admitted 
with  retention  of  urine.  Fetid  urine  was  drawn  off.  A  fietus 
of  three  or  four  months  was  ex])elled  followed  by  its  placenta. 
Then  incontinence  ensued.  The  urine  was  still  offensive,  and 
loaded  with  mucus.  Twelve  days  later  she  was  seized  with  great 
pain  over  the  pubic  region.     Next  morning  the  house  surgeon  was 


ORGANIC  DISEASES  OF  THE  BLADDER.  Y65 

called  to  see  lier  on  account  of  excessive  pain.  He  felt  a  substance 
being  expelled,  and  saw  a  mass  protruding  throngb  the  meatus  uri- 
narius.  This  was  expelled  in  half  an  hour.  At  the  moment  of  ex- 
pulsion the  urine  gushed  out  in  great  force  and  in  large  quantity. 
Instant  relief  followed,  and  she  perfectly  recovered.  The  substance 
looked  as  if  it  were  the  whole  mucous  coat  of  the  bladder.  Its 
inner  surface  was  coated  with  gritty  deposits.  Its  minute  structure 
is  not  described."  Barnes  has  no  doubt  but  that  the  retention  was 
in  this  case  caused  by  retroversion  of  the  gravid  uterus. 

One  of  Mr,  Spencer  Wells's  cases,  also  cited  by  Barnes  {loc.  cit), 
is  very  instructive  :  "  A  woman,  aged  22,  had  a  natural  labor  with 
her  first  child.  The  bladder  was  not  emptied  for  sixty-two  hours. 
Five  pints  of  turbid,  bloody  urine  were  then  drawn  off.  Cystitis  fol- 
lowed, then  incontinence  of  urine,  and  a  train  of  distressing  cerebral 
symptoms,  ending  in  death  two  months  after  delivery.  The  bladder 
after  death  was  found  to  contain  a  detached  cast,  lying  loose,  cov- 
ered with  gritty  deposits  of  urates  and  phosphates.  The  walls  of 
the  bladder  were  thick  and  contracted,  the  muscular  fibers  being 
distinctly  visible.  The  cast  resembled  degenerated  epithelium. 
On  boiling  a  piece  of  it  in  dilute  acetic  acid,  much  of  the  saline 
matter  became  dissolved,  and  some  of  the  tissue  became  clear,  look- 
ing like  smooth  muscular  tissue  which  had  begun  to  degenerate,  as 
shown  by  the  deposit  of  fatty  or  albuminous  particles  in  its  sub- 
stance." 

Further  pathological  results  may  follow  the  prolonged  retention 
of  urine.  The  bladder  having  reached  a  certain  point  where  no 
more  urine  can  enter  it,  and  even  before  this  time,  the  ureters  are 
filled  from  the  urine  above,  and  as  the  renal  pelves  fill,  both  they 
and  the  ureters  are  put  greatly  on  the  stretch.  The  kidneys  con- 
tinue to  secrete  urine  until  the  pressure  in  the  urinary  tubules  equals 
that  of  the  blood  in  the  glomerulus.  At  that  point  all  secretion 
ceases,  and  pressure  on  the  emulgent  veins  becomes  so  great  that  de- 
generative changes  are  apt  to  take  place.  In  some  cases  after  the 
pressure  is  relieved,  acute  nephritis  results.  The  urine  following 
such  a  condition  of  distention  is  loaded  with  hyaline,  granular,  and 
epithelial  casts,  and  epithelial  elements  from  the  kidneys. 

The  following  ease,  which  occurred  in  the  practice  of  Dr.  Geo. 
W.  Gushing,  of  this  city  (the  doctor  having  kindly  furnished  me 
with  a  report  of  it),  may  serve  as  an  illustration  of  what  I  have  been 
saying : 

"  Mrs.  S.,  of  New  York,  aged  twenty-six  ;  married  eight  years  ; 
one  child  ;  catamenia  regular ;  appetite  fair ;  bowels  sluggish  ;  no 


766  DISEASES  OP  WOMEN. 

dysuria  previous  to  present  attack.  Has  been  under  treatment  for 
the  past  two  months  for  cervical  endometritis.  Local  applications  of 
mild  astringents  and  glycerin,  with  injections  of  borax.  Tonics 
and  laxatives  internally.  There  being  some  tendency  to  tubercu- 
losis, she  was  given  cod-liver  oil. 

"I  was  called  to  see  this  patient  May  29,  187Y.  She  told  me 
she  was  suffering  from  internal  haemorrhoids,  and  that  the  lectal 
tenesmus  was  very  distressing.  She  had  had  similar  attacks  before, 
and  seemed  to  have  no  doubt  as  to  what  the  trouble  was.  As  she 
was  menstruating  I  made  no  examination,  but  advised  rest  and  a 
laxative  powder,  to  be  followed  by  morphia  suppositories. 

"  May  30. — Bowels  moved  since  last  visit  with  considerable 
pain.  Complained  of  some  vesical  irritation,  but  had  passed  urine. 
Not  much  relief. 

"J/«y  31st. — No  better.  An  examination  showed  no  haemor- 
rhoids. Menses  ceased.  Vaginal  examination  revealed  a  very  sensi- 
tive spot,  with  hardening  on  the  right  side,  between  the  rectum  and 
vagina.  Pulse  and  temperature  slightly  elevated.  Vesical  and  rec- 
tal tenesmus,  but  no  trouble  in  passing  water.  Made  diagnosis  of 
probable  pehac  abscess.  Advised  poultices  to  the  perinseum,  warm 
applications  over  the  abdomen,  and  gave  anodynes.  Patient  much 
relieved  by  the  treatment,  but  still  having  severe  pelvic  distress. 

''  June  2d. — Condition  the  same. 

^'June  3d. — Found  the  vesical  distress  increased.  Her  husband 
said  that  she  had  passed  urine  during  the  night.  Was  called  to  her 
in  the  afternoon,  and  found  her  in  great  suifering.  Said  that  her 
husband  had  misinformed  me,  and  that  she  had  passed  no  urine  for 
about  thirty  hours.  I  examined  the  abdomen,  and  found  dullness 
well  up  to  the  umbilicus.  Introducing  a  catheter,  I  drew  off  a  large 
quantity  of  very  offensive,  high-colored  urine,  with  much  relief  to 
the  patient.  For  the  next  two  days  I  was  obliged  to  use  the  cath- 
eter. An  exaiuination  of  the  urine  drawn  off  was  made,  and  showed 
the  presence  of  renal  epithelium,  granular,  hyaline,  and  epithelial 
casts,  and  considerable  albumen,  as  also  epithelium  from  the  bladder 
and  ureters. 

"  June  5th. — T  found  a  tendency  of  the  inflammatory  products 
in  the  pelvis  to  point  about  the  center  of  the  perina^um,  and,  tliough 
not  quite  sure  of  pus,  I  punctured  and  evacuated  quite  a  large  amount 
of  it. 

"  Since  then  the  treatment  has  been  the  use  of  alkalies  and  sooth- 
ing drinks — tr.  ferri  chloridi — and  washing  out  the  bladder  with 
lukewarm  water  containing  salt  and  a  little  carbolic  acid.     The  ab- 


ORGANIC   DISEASES  OP  THE   BLADDER.  767 

scess  remaining  open  and  very  sluggish  for  some  time,  I  put  the 
patient  under  ether,  and  performed  the  operation  for  fistula  in  ano. 
At  the  present  writing,  October  30th,  Mrs.  S.  is  in  excellent  condi- 
tion, having  gained  in  flesh  and  strength,  and  being  no  longer  trou- 
bled with  the  vesical  disorder." 

This  case  is  not  only  interesting  as  showing  the  serious  changes 
that  may  occur  in  the  kidneys  from  vesical  distention,  but  as  illus- 
trating the  occurrence  of  retention  of  urine  from  reflex  nervous  in- 
fluence. Abscesses  about  the  rectum  are  especially  prone  to  cause 
retention.  Although  in  this  case  the  mischief  done  to  the  kidneys 
was  soon  corrected,  it  does  not  follow  that  it  will  be  so  readily 
accomplished  in  all  cases,  especially  if  the  retention  continues  un- 
relieved for  any  length  of  time. 


CHRONIC  CYSTITIS. 

Pathology. — In  chronic  cystitis  the  redness  of  acute  inflamma- 
tion gradually  gives  way  to  a  muddy  gray  color,  the  membrane  being 
smeared  in  places  with  a  dark  yellow  muco-purulent  secretion.  As 
the  disease  advances,  there  is  excessive  cell  growth  on  the  free  mu- 
cous surface.  Patches  of  ulceration  appear  here  and  there,  attended 
with  the  formation  of  pus  and  occasional,  though  usually  slight, 
haemorrhages.  Sometimes,  at  the  portions  destroyed  by  ulceration, 
the  process  of  hyperplasia  is  established,  and  a  polypoid  material  is 
developed.  This  has  the  appearance  of  exuberant  granulations,  as 
seen  on  a  healing  sore.  At  other  times,  and  even  in  portions  of  the 
same  organ  in  which  hyperplasia  occurs,  the  process  of  ulceration 
advances.  The  submucous  intermuscular  tissue  partakes  of  the 
inflammatory  trouble,  and  thickening  of  the  vesical  walls  results. 
The  decomposed  urine,  mixed  with  pus,  mucus,  blood,  and  shreds 
of  membrane,  forming  the  chocolate-colored  fluid  found  in  the 
advanced  stages  of  this  disease,  acts  as  an  irritant  on  the  unhealthy 
membrane,  and  produces  deeper  or  fresh  ulceration. 

In  advanced  cases,  with  deep  ulceration,  the  muscular  fibers 
(which  resist  the  destructive  processes  longest)  are  occasionally  seen, 
stretching  from  one  side  of  an  ulcer  to  the  other,  forming  a  sort  of 
bridge.  When  the  end  of  one  of  these  fibers  becomes  detached,  it 
floats  like  a  filament  in  the  contents  of  the  bladder.  In  some  cases 
the  salts  of  the  urine  are  deposited,  and  form  incrustations  on  the 
ragged  mucous  membrane. 

I  remember  that  one  of  my  patients  frequently  passed  lumps  of 
material  that  on  examination  proved  to  consist  of  all  these  products 


Y68  DISEASES  OF  WOMEN. 

of  destructive  mflammation,  among  whicli  were  mixed  deposits  of 
the  urinary  salts  in  the  form  of  hard,  gritty  particles. 

In  cases  of  long  standing,  the  vesical  ends  of  the  ureters  are 
obstructed  by  swelling  and  hypertrophy  of  the  bladder- walls.  This 
produces  obstruction  to  the  free  flow  of  urine,  and  leads  to  dilatation 
of  the  ureters  and  renal  pelves,  and  in  some  cases  organic  disease  of 
the  kidneys  follows  in  the  train  of  pathological  sequences.  J  wnll 
refer  to  this  subject  again. 

When  the  disease  has  destroyed  the  nuicous  membrane  partially 
or  wholly,  and  extends  to  the  muscular  parietes,  we  have  what  is 
known  as  interstitial  cystitis,  and,  if  the  serous  coat  becomes  in- 
volved, there  is  also  pericystitis.  This  latter  is  simply  an  inflam- 
mation of  that  portion  of  the  pelvic  peritonaeum  which  covers  the 
bladder.  In  interstitial  cystitis,  after  destruction  of  portions  of  the 
mucous  membrane  by  ulceration,  the  areolar  tissue  beneath  it  and  in 
the  muscular  walls  gives  way,  the  muscular  liber  generally  becomes 
thickened  and  burrowed  by  ulcerated  cavities,  irregular  in  form,  and 
surrounded  by  cicatricial  tissue.  The  extreme  hypertrophy  of  the 
muscular  coat  found  in  the  bladder  of  the  male  under  these  circum- 
stances does  not  so  commonly  exist  in  that  of  the  female. 

In  epi-  or  peri-cystitis  the  peritoneal  coat  is  found  to  be  hyper- 
semic  and  thickened  by  exudation,  and  the  adhesions  which  follow 
bind  together  the  bladder  and  the  neighboring  organs.  Perforation 
of  the  pentonaeum  sometimes  occurs,  allowing  inflltration  of  the 
urine.  Tliis  usually  develops  general  peritonitis  or  septicaemia,  or 
both,  and  death  almost  inevitably  follows. 

I  have  already  stated  that  the  walls  of  the  bladder,  including  the 
serous  coat,  may  become  involved  by  the  extension  of  a  primary 
inflammation  of  the  mucous  membrane.  This  is  undoubtedly  the 
usual  mode  of  occurrence,  but,  in  some  cases,  I  think  that  all  of  the 
bladder  coats  may  become  inflamed  at  the  same  time,  making  an 
inflammation  in  toto.  At  least,  it  is  a  fact  that  in  some  cases  the 
mucous,  muscular,  and  serous  layers  of  the  organ  in  question  become 
involved  in  such  rapid  succession  as  to  prevent  us  from  detecting  its 
progress  from  one  tissue  to  another. 

The  inflammatory  process,  having  traversed  the  mucous  and  mus- 
cular coats,  and  involved  the  serous,  especially  where  ulceration  of 
the  mucous  membrane  accompanies  it,  is  likely  to  extend  to  the 
other  portions  of  the  pelvic  peritonaeum  and  cellular  tissue  if  the 
patient  lives  sufficiently  long. 

It  will  be  observ^ed  that  in  this  condition  there  is  about  the  same 
pathological  anatomy  as  in  pelvic  peritonitis  and  cellulitis  where  in- 


ORGANIC   DISEASES  OP  THE   BLADDER.  YG9 

ilammation  of  tlie  bladder-walls  is  caused  by,  and  consequently  sec- 
ondary to,  the  pelvic  intiamniation.  In  such  condition  the  kidneys 
and  ureters  are  usually  found  diseased.  In  some  cases  the  cellular 
tissue  about  the  bladder  becomes  greatly  increased,  and  occasionally 
abscesses  form,  as  in  ordinary  pelvic  cellulitis. 

I  am  satisfied  tliat  the  disease  described  in  some  of  the  text-books 
as  idiopathic  pericystitis  is,  in  almost  all  cases,  when  it  occurs  in 
women,  a  pelvic  peritonitis  originally,  the  bladder  becoming  aflfected 
secondarily. 

One  of  the  most  serious  results  of  intense  vesical  inflammation 
is  gangrene.  The  bladder  becomes  distended  from  paralysis  of  its 
muscular  walls,  and  its  contents  are  found  to  be  a  brownish  colored 
fluid,  consisting  of  decomposed  urine,  shreds  of  broken-down  mucous 
membrane,  altered  blood,  pus,  epithelial  elements,  and  urinary  salts. 
The  mucous  membrane  is  found  to  be  soft,  pultaceous,  and  altered 
in  color,  the  latter  varying  from  a  deep,  charred  black  to  a  dark 
greenish  or  greenish  yellow. 

The  submucous  connective-tissue  layer  and  the  muscular  coat  are 
softened,  discolored,  and  infiltrated  with  malodorous  pus.  The  peri- 
tonaeum is  also  injected,  and  in  places  discolored,  sometimes  per- 
forated, and  having  undergone  fatty  degeneration.  This  complica- 
tion usually  occurs  in  the  course  of  chronic  cystitis  with  considerable 
ulceration,  and  in  which  an  acute  inflammation  is  lighted  up, 
there  not  being  sufiicient  vitality  left  to  prevent  rapid  and  deep 
gangrene. 

These  extreme  forms  of  cystitis  are  rare,  and  occur  generally  in 
connection  with  abnormal  cases  of  labor,  A  pregnant  woman  having 
a  cystitis  of  a  mild  form  is  liable  to  develop  acute  general  cystitis 
at  her  confinement.  Again,  inflammation  and  gangrene  of  the  blad- 
der sometimes  follow  instrumental  or  manual  delivery  in  which 
severe  contusions  of  the  bladder  have  occurred, 

I  desire  now  to  call  attention  to  some  of  the  effects  of  cystitis  on 
the  ureters  and  kidneys.  That  form  of  vesical  inflammation  known 
as  chronic  cystitis  may  travel  up  the  ureters  to  the  kidneys,  produc- 
ing ureteritis,  pyelitis,  pyonephrosis,  or  renal  abscess.  This  affec- 
tion seems  more  commonly  to  attack  the  left  ureter  and  kidney.  I 
say  seems,  that  being  simply  my  opinion,  derived  from  the  cases 
that  I  have  seen  or  of  which  I  have  read.  I  know  of  no  statistics 
upon  the  subject.  This  complication  is  not  so  common  in  females 
as  in  males,  which  is  owing,  perhaps,  to  the  fact  that  their  short  ure- 
thra, being,  as  a  rule,  free  from  stricture,  and  seldom  obstructed 
otherwise  for  any  length  of  time,  the  inflammation  of  the  bladder 
50 


YYO  DISEASES  OF  WOMEN. 

has  less  tendency  to  extend,  is  less  severe,  and,  as  a  rule,  is  earlier 
and  more  easily  treated  locally  than  in  the  male. 

It  can  not  be  denied  that  the  damming  back  of  urine  into  the 
ureters  and  renal  pelves  is  a  factor  in  the  production  of  disease  in 
these  parts.  Suppose  that  an  inflamed  ureter  becomes  blocked  up 
from  any  cause  (a  mucous,  purulent,  or  blood  plug ;  by  the  impaction 
of  a  small  calculus  from  the  kidney  ;  thickening  of  its  mucous  mem- 
brane ;  or  hypertrophy  of  the  bladder-walls),  the  urine  behind  the 
point  of  obstruction  greatly  distends  the  ureter  and  renal  pelvis,  de- 
composes, and  produces  acute  pyelitis,  which  often  leads  to  destruc- 
tion of  the  kidney  on  that  side. 

In  post-mortem  examinations  of  such  cases  it  will  be  found  that 
the  mucous  meml)rane  of  the  dilated  ureter  and  pelvis  of  the  kid- 
ney is  swollen,  pulpy,  and  of  a  dirty-drab,  grayish,  or  greenish  color, 
and  possibly  with  incrustations  of  saline  matter  upon  its  surface. 
The  renal  pelvis  may  be  sacculated,  and  the  pouches  may  contain 
shreds  of  membrane,  thickened,  dirty  pus,  and  saline  matter.  The 
kidney,  when  free  from  organic  lesion,  is  always  sympathetically 
affected,  being  enlarged  and  congested.  Abscesses  of  the  kidney 
itself  have  been  found  in  these  cases. 

The  inflamed  and  dilated  pelvis  of  the  kidney,  gradually  enlarg- 
ing, flattens  out,  and  implicates  the  papilliie,  and  later  the  pyramids 
in  the  inflammatory  process,  until,  finally,  the  whole  organ  is  con- 
verted into  a  sacculated  abscess. 

When  there  is  destructive  inflammation  of  the  kidney  (the  ureter 
not  being  obstructed,  and  the  pus  having  a  free  exit),  the  organ 
shrinks  until  it  is  converted  into  a  little  shriveled  body,  weighing 
from  a  few  drachms  to  an  ounce  or  two.  If  the  purulent  matter  has 
not  free  exit,  it  fills  the  kidney,  and  becomes  thick  and  putty-like, 
cutting  like  fresh  cheese.  This  may  be  the  case  where  the  punilent 
matter  can  not  or  does  not  escape  from  the  kidney,  the  ureter  being 
perfectly  free  throughout.  The  septa  between  the  sacculi  are  occa- 
sionally calcified. 

The  pyramids  alone  may  suffer,  their  tissue  being  converted  into 
purulent  matter,  the  whole  having  the  appearance  of  soft  putty,  in 
some  cases  studded  with  calcareous  masses.  When  the  purulent 
matter  is  washed  out,  the  hole  left  looks  as  though  the  pyramid  had 
been  punched  out,  so  smooth  and  clean  cut  are  its  edges. 

Again,  the  kidneys  may  be  studded  wi;;h  miimte  abscesses. 
Where  one  kidney  is  wholly  or  partially  destroyed,  the  other,  if 
healthy,  is,  as  a  rule,  largely  hypertrophied. 

In  some  cases  of  long  standing  the  affected  kidney  does  not  break 


ORGANIC  DISEASES  OP   THE   BLADDER.  771 

down  into  purulent  matter,  but  by  a  slower  process,  probably  that 
of  chronic  congestion,  becomes  granular  and  contracted. 

The  study  of  the  renal  complications  of  cystitis  is  a  very  interest- 
ing and  instructive  one,  but  it  is  too  extensive  to  permit  of  anything 
like  a  full  discussion  here.  For  a  more  elaborate  consideration  of 
the  subject,  I  must  refer  to  the  special  books  on  renal  diseases. 

Symptomatology. — The  various  forms  of  cystitis  being  simply 
stages  of  the  same  disease,  I  shall  speak  of  their  symptoms  all  under 
one  head. 

They  may,  for  convenience  sake,  be  divided  as  follows : 

1.  Symptoms  referable  to  the  organ  or  its  contents. 

2.  Symptoms  referable  to  neighboring  organs,  that  suffer  either 
from  sympathy  or  through  direct  extension. 

3.  Symptoms  referable  to  various  conditions  of  the  general  sys- 
tem, as :  («)  The  vascular  system,  (h)  The  digestive  tract,  (c)  The 
cutaneous  surface,  {d)  The  nervous  system — cephalic  and  sub- 
cephalic. 

1.  The  symptoms  referable  to  the  organ  itself  are  chiefly  de- 
rangement of  function — viz.,  pain,  tenesmus,  and  frequent  urination. 
The  symptoms  vary  in  severity  according  to  the  extent  and  intensity 
of  the  cystitis.  In  the  mildest  form  of  the  trouble  there  is  frequent 
desii-e  to  pass  water,  which  often  comes  with  unusual  force.  Mic- 
turition is  followed  by  a  desire  to  strain,  called  vesical  tenesmus,  as 
if  the  organ  had  not  been  fully  emptied.  In  the  more  acute  cases 
this  gives  rise  to  the  most  intense  agony,  the  patient  remaining  on 
the  vessel  for  hours  at  a  time.  The  sensation  of  a  few  drops  of  urine 
remaining  in  the  bladder  may  pass  off  in  a  few  moments,  but,  as  a 
rule,  returns  after  each  micturition. 

As  the  disease  advances,  and  ulcerative  changes  take  place,  this 
vesical  tenesmus  returns  in  full  force,  and  the  powerful  squeezing 
together  of  the  bladder-walls  during  and  after  urination  produces 
intense  pain.  Sometimes  pains  shoot  up  into  the  breast  or  the  re- 
gion of  the  umbilicus.  There  is  often  a  dull,  heavy  aching  in  the 
perinseum.  In  nearly  all  cases  there  is  continuous  backache,  or,  more 
correctly,  sacral  pain.  These  pains  seem  to  be  most  severe  in  cases 
of  long  standing,  where,  upon  an  already  ulcerated  surface,  an  acute 
inflammation  is  set  up  by  errors  in  diet,  medicines,  violence  in  cath- 
eterization, rapid  changes  in  temperature,  and  the  weather. 

The  condition  of  the  urine  in  acute  or  chronic  cystitis  is  of  im- 
portance, but  if  reliance  is  placed  upon  it  alone  for  a  diagnosis  there 
w\\\  be  many  disappointments.  The  specific  gravity  is  usually  low 
in  the  more  chronic  types,  varying  from  1*005  to  1*018,  being  usu- 


7Y2  DISEASES  OP  WOMEN. 

ttally  about  I'OIO.  In  the  primary  acute  form  the  gravity  is  little 
if  anything  below  the  normal,  and,  if  there  is  marked  fever,  may 
rise  as  high  as  1*030.  In  acute  attacks  engrafted  on  a  chronic  state, 
the  gravity  is  usually  low.  When  the  specific  gravity  is  low  in  acute 
cystitis,  if  not  dependent  on  the  diluent  drinks  and  diuretics  given, 
it  is  probably  due  to  a  slight  sympathetic  hyperaemia  of  the  kidneys. 
The  low  gravity  in  chronic  cystitis  is  possibly  due  to  the  same  cause, 
and  a  urine  not  only  proportionally  but  really  deficient  in  the  urin- 
ary salts  is  excreted.  To  this  may  be  attributed  many  of  the  urseniic 
(ammonsemic)  symptoms  accompanying  the  disease,  which  are  sup- 
posed by  many  to  be  due  to  absorption  of  decomposed  urine.  That 
such  absorption  might  take  place  after  ulcerative  processes  had  be- 
gun, or  even  slight  epithelial  erosion  had  taken  place,  there  can  be 
no  doubt;  but  it  is  a  question  whether  we  are  to  look  to  the  absorp- 
tion from  the  eroded  bladder  as  the  only  method  of  their  production. 
I  shall  speak  of  this  more  fully  very  soon. 

The  reaction  of  the  urine  in  acute  cases,  when  the  affection  is 
not  due  to,  or  accompanied  by,  retention,  is  at  first  usually  acid.  If 
there  be  retention,  the  reaction  is  usually  alkaline,  due  partly  to  the 
fixed  alkali  of  the  mucus  which  is  present  in  excess,  but  chiefly  to 
the  ammonia  disengaged  in  the  breaking  down  of  the  urea.  In 
chronic  cystitis  the  reaction  is  almost  invariably  alkaline,  being  in- 
tensely ammoniacal. 

In  the  primary  acute  form,  the  color  is  but  slightly  altered. 
The  presence  of  a  little  blood  may  give  to  the  urine  a  smoky  tint, 
and  if  decomposed  it  will  look  hazy  and  perhaps  contain  sparkling 
crystals  of  the  triple  phosphate.  In  the  chronic  form  the  urine  is 
of  a  pale,  dirty  yellow  hue,  and  may  be  of  a  deep  red  from  the 
presence  of  considerable  blood. 

The  odor  is  ammoniacal  in  the  acute  type,  if  the  urine  be  de- 
composed, otherwise  it  is  normal  In  tlie  chronic  form  it  has  not 
only  an  ammoniacal  but  a  peculiar  pungent  odor  of  flesh.  This  is 
usually  known  as  organic,  from  the  fact  that  it  is  due  to  the  amount 
of  organic  material  present. 

The  sediment  in  acute  cystitis  is  usually  mucus,  sometimes  pus 
(white  and  clinging  to  the  bottom,  or  somewhat  flocculent).  It  may 
be  tinged  with  ])lood,  or  rendered  denser  and  whiter  from  the  pres- 
ence of  the  amorphous  and  triple  ])hosphates.  In  chronic  cystitis 
the  sediment  is  commonly  heavy,  and  of  a  dirty  brown  or  brownish 
yellow  color.  Flakes  of  pus,  shreds  of  tissue,  as  well  as  blood  and 
epithelial  elements,  cause  it  to  vary  greatly  in  different  cases. 
When  the  intense  alkalinity  of  the  urine  has  rendered  the  pus  gelat- 


ORGANIC  DISEASES  OF  THE  BLADDER.  YY3 

inouSj  the  sediment  is  seen  as  a  ropy  mass  that  clings  tenaciously 
to  the  bottom  of  the  vessel  when  inverted,  or  slides  about  in  a  jelly- 
like mass. 

•Microscopically,  this  sediment  presents  a  varied  and  interesting 
appearance.  In  the  acute  form  numerous  fibrillse  of  mucus,  a  few 
pus-corpuscles,  and  possibly  blood-globules  are  to  be  seen,  and  if  de- 
composition has  taken  place,  the  amorphous  and  triple  phosphates. 

In  chronic  cystitis  pus-corpuscles  are  usually  present  in  large 
amount.  There  is  also  a  varying  amount  of  mucus,  triple  and  amor- 
phous phosphates,  spheres  of  the  urate  of  ammonia,  organic  debris, 
and  in  some  cases  epithelial  elements.  In  the  advanced  stages  of 
chronic  cystitis  epithelial  elements  of  any  kind  are  very  rarely  found. 
It  is  only  in  the  earher  stages  that  normal  and  transitional  forms  of 
vesical  epithelium  are  present.  Even  then  dependence  must  not  be 
placed  upon  that  alone  in  making  a  differential  diagnosis,  lest  a  pye- 
litis may  be  mistaken  for  a  cystitis,  or  vice  versa ;  the  transitional 
forms  of  epithelium  from  the  bladder  closely  resembling  the  nor- 
mal epithehum  from  certain  other  parts  of  the  urinary  tract.  The 
return  to  a  healthy  condition  is  marked  by  the  disappearance  of  pus  ; 
the  reappearance  of  epithelium  in  the  urine,  first  transitional,  then 
perfect ;  while  the  products  of  inflammation  decrease  in  amount  and 
finally  disappear  altogether.  When  there  is  sympathetic  congestion 
of  the  kidneys,  small  light  granular  and  hyaline  casts  may  be  found. 
If  organic  renal  disease  is  present,  large,  small,  and  medium-sized 
hyaline,  light  and  dark  granular,  and  pus  casts  will  be  found,  as 
also  epithelial  and  blood  casts.  In  some  cases,  where  extensive  de- 
structive change  has  taken  place  in  the  kidneys,  no  evidences  are 
found  in  the  urine,  either  during  its  progress  or  after  its  completion. 

Upon  testing  the  urine  chemically,  albumen  wiU  be  found  in 
proportion  to  the  amount  of  pus  or  blood  present.  If  renal  disease  co- 
exist, the  amount  of  albumen  will  be  greatly  increased.  In  chronic 
cystitis  without  renal  disease  the  amount  of  albumen  in  a  number 
of  cases  studied  varied  from  one  sixteenth  to  one  fifth  of  the  bulk 
of  urine.  There  is  usually  a  real  excess  of  both  fixed  and  volatile 
alkaline  salts,  as  also  of  the  earthy  and  alkaline  phosphates  and  the 
chloride  of  sodium. 

In  the  advanced  stages,  where  there  is  a  depraved  condition  of 
the  blood,  urohaematin  is  present  in  a  marked  degree,  and  ui"ea  is 
either  somewhat  or  decidedly  diminished.  In  other  cases,  and  at 
first,  the  urea  may  be  present  in  normal  amount. 

2o  Symptoms  Referable  to  Neighboring  Organs. — These  are  not 
especially  marked.     In  some  cases,  with  the  intense  vesical  tenes- 


774  DISEASES  OP  WOMEN. 

mus,  there  may  exist  an  irritable  condition  of  the  rectum,  with  some 
tenesmus  and  pain  at  stool. 

The  uterus  is  often  congested,  which  causes  a  free  leucorrhoea ; 
subinvolution  often  occurs  after  the  coniinement  of  those  who  have 
had  cystitis  during  pregnancy.  Extension  of  the  inflammation  in 
extreme  cases  may  cause  metritis  and  pelvic  cellulitis  and  perito- 
nitis. The  symptoms  thus  arising  will  be  characteristic  of  the  dis- 
ease of  the  organs  or  tissues  involved. 

Menstruation  may  be  variously  disturbed ;  menorrhagia,  metror- 
rhagia, or  amenorrhoia  resulting  either  from  congestion,  infllamma- 
tory  extension,  or  reflex  nervous  influence. 

Neuralgia  of  the  uterus  or  ovaries  may  also  be  produced  in  this 
way.  I  have  just  said  that  subinvolution  of  the  uterus  is  almost 
sure  to  follow  a  pregnancy  occurring  during  the  existence  of  a 
chronic  vesical  inflammation,  and  I  am  inclined  to  believe  that  the 
same  result  is  produced  in  some  cases  by  an  acute  cystitis  following 
delivery. 

Renal  disturbances  upon  which  I  have  already  touched  will  be 
spoken  of  more  at  length  hereafter. 

3o  Symptoms  Referable  to  Disturbances  of  the  General  System. — 
These  symptoms  may  be  due  to  reflex  nervous  influence,  or  to  di- 
rect blood-poisoning.     For  convenience  sake  I  will  first  consider : 

(«)  The  Vascular  Sydem. — Although  there  has  been  much  dis- 
pute among  authors  as  to  how  and  by  what  the  general  poisoning  is 
caused,  there  seems  to  be  no  question  as  to  whether  such  a  poison- 
ing really  does  take  place.  As  general  systemic  effects  may  be  pro- 
duced by  two  separate  blood  conditions,  I  will  discuss  the  subject 
under  two  heads,  prefacing  their  consideration,  however,  with  the 
remark  that,  as  a  rule,  the  two  conditions  exist  together.  They  are : 
first,  abnormal  ingredients  existing  in  the  blood;  and,  second,  a  poor 
condition  of  the  blood  itself  (anaemia). 

The  poisoning  of  the  general  s^'stem  that  usually  complicates 
cystitis  of  long  standing  may  be  produced  in  three  ways,  viz  : 

1.  Organic  renal  disease,  or  renal  hyperaemia  (sympathetic), 
leading  to  imperfect  elimination  of  urinary  salts. 

2.  Direct  absorption  of  one  or  more  of  the  ingredients  of  the 
decomposed  urine  (ammonsemia,  urineemia). 

3.  Absorption  of  purulent  or  septic  matter,  produced  by  decom- 
position of  sloughing  tissue  and  organic  debris. 

1.  Probably  in  almost  all  cases  of  chronic  cystitis  the  kidneys 
are  kept  in  a  more  or  less  active  or  passive  hyperaemic  state ;  and 
while  eliminating  a  normal  amount  of  fluid,  fail  to  rid  the  blood  of 


OEGANIC  DISEASES  OF  THE  BLADDER.  Y75 

the  accumulating  salts ;  and  thereby  a  slow,  steady  blood  and  tissue 
poisoning  is  brought  about.  So  slow  is  it,  that  the  system  seems  to 
establish  a  certain  amount  of  tolerance  tor  the  poison. 

A  French  experimenter  has  found  that  a  small  amount  of  urea 
is  daily  eliminated  by  the  mucous  membrane  of  the  bowels  in 
health,  and  we  know  that  in  renal  diseases,  with  partial  or  total  sup- 
pression of  urine,  the  bowels  are  largely  concerned  in  the  elimina- 
tion of  the  poison  from  the  system.  In  this  manner  may  be  ex- 
plained the  occasional  attacks  of  vomiting  and  almost  uncontrollable 
diarrhoea  in  bad  cases  of  cystitis.  Of  course,  when  destructive  renal 
disease  complicates  the  cystitis,  the  general  poisoning  is  more 
marked  and  more  readily  explained. 

2.  In  the  chapter  on  the  function  of  the  bladder  I  pointed  out 
that  experimenters  had  pretty  well  established  the  fact  that  a  nor- 
mal vesical  mucous  membrane  was  unable  to  absorb  anything  except 
possibly  a  little  water,  but  that  where  erosion  of  the  epithelial  surface 
or  ulceration  existed,  absorption  was  possible.  This  being  the  case, 
it  will  at  once  be  seen  how  easy  it  is  for  a  patient  suffering  with 
chronic  cystitis  to  become  poisoned  by  the  absorption  of  decomposed, 
ammoniacal  urine  in  the  bladder.  Whether  the  materies  morhi 
be  the  urea,  the  ammonia,  or  all  or  part  of  the  urine,  is  not  as  yet 
deiinitely  settled.  This  form  of  poisoning  by  absorption  has  been 
denied  on  the  ground  that  the  urine  remains  but  a  short  time  in 
the  bladder  owing  to  the  intense  vesical  tenesmus,  and  that  the 
eroded  surface  is  fairly  well  shielded  from  contact  with  the  urine  by 
mucus  or  gelatinous  pus,  and  that  therefore  there  is  neither  time  nor 
opportunity  for  absorption.  As  against  these  arguments,  let  me  say 
that  of  all  kinds  of  urine,  the  highly  limpid  seems  the  most  easily 
absorbed ;  that  poisoning  is  not  supposed  to  be  due  to  the  fresh 
urine  that  comes  directly  from  the  kidneys,  but  to  its  decomposing 
sediment,  caught  in  the  meshes  of  the  mucus  and  muco-pus.  Fur- 
ther, the  intense  vesical  tenesmus,  while  keeping  the  bladder  com- 
paratively empty,  thoroughly  mixes  the  decomposing  urine  with 
the  mucus,  thus  at  each  micturition  applying  freshly  charged  de- 
composing matter  to  the  eroded  and  ulcerated  surface.  It  will  also 
be  observed  that  in  some  cases  where,  by  the  use  of  opiates  or  in  the 
course  of  the  disease  itself,  the  tenesmus  wholly  or  in  part  abates 
and  the  urine  remains  in  the  bladder  for  a  longer  period  than  usual, 
the  patient,  while  feeling  greatly  relieved  by  not  having  the  inces- 
sant calls  to  urinate,  still  begins  to  experience  a  peculiar  sensation 
of  sleepiness  and  the  other  manifestations  of  systemic  poisoning. 
That  this  is  not  due  to  the  opiates  or  other  remedies  used,  is  evident 


776  DISEASES  OF  WOMEN. 

from  the  fact  that  as  large  or  larger  doses  of  the  same  remedies  do 
not  j^roduce  these  peculiar  results  when  given  at  times  when  the 
vesical  tenesmus  is  marked.  It  is  midoul)tedly  explained  by  the 
fact  that  the  bladder  has  more  time  to  absorb  a  part  of  its  contents, 
which,  when  absorbed,  produce  these  results. 

3.  Blood  contamination  due  to  the  absorption  of  purulent  or  sep- 
tic matter. — This  material  may  l)e  the  liquor  jpui'is^  the  disinte- 
grated corpuscles  of  jdus,  or  possibly  the  whole  corpuscles,  as  also  the 
decomposed  shreds  of  sloughed  membrane  and  organic  debris. 

I  think  there  is  little  doubt  but  that  feuch  material  is  at  times  ab- 
sorbed, and  gives  rise  to  the  peculiar  septicsemic  or  pysemic  symp- 
toms. The  chill,  fever,  and  sweating,  with  peculiar  head  symptoms 
(all  to  be  spoken  of  more  fully  hereafter),  the  sudden  diarrhoea,  with 
copious  black,  oifensive  liquid  stools,  are  probably  caused  in  this  way. 

Whether  the  general  symptoms  are  produced  at  the  time  of  each 
absoi"ption,  or  whether  by  slow  degrees  the  poisonous  material  col- 
lects, and,  tolerance  being  finally  exhausted,  nervous  disorder,  with 
a  powerful  effort  at  excretion  by  the  bowels,  results,  we  do  not 
know. 

■i.  Depraved  blood  condition  —  (anaemia). — In  cystitis  of  long 
standing,  owing  to  frequent  ha3morrliages,  poor  digestion,  excessive 
diaphoresis  and  diuresis,  and  reflex  nervous  influences,  the  blood  be- 
comes poor  in  red  corpuscles  and  fibrin.  Injuries  on  persons 
thus  affected  do  not  heal  readily,  and  poor  tissue  renovation  is  a 
general  accompaniment  of  this  affection.  Cerebral  aufemia  is  an 
accompanying  complication,  due  to  the  same  cause,  and  various  ab- 
normal nervous  phenomena  result  from  poor  nourishment  of  nerve- 
tissue.  All  the  fluids  and  solids  of  the  body  are  but  pcorly  con- 
structed, and  imperfect  performance  of  function  necessarily  results. 
This  poor  blood  condition,  as  I  have  already  said,  is  manifested  by 
the  presence  of  urohseraatin  in  the  urine. 

(Jj)  The  Digestive  TraH — Anorexia,  especially  at  the  morning 
meal,  is  a  common  accompaniment  of  chronic  cystitis.  In  some  cases 
this  is  the  only  meal  where  the  appetite  does  not  invite  the  patient 
to  partake.  A  longing  for  peculiar  foods  is  also  very  common,  the 
patient  often  having  lost  the  desire  before  the  article  in  question 
reaches  her.  The  common  symptoms  of  disordered  digestion  are 
usually  present,  and  the  affection  may  be  either  of  the  nervous  type, 
or  of  the  chronic  catarrhal  form  ;  it  is  usually  a  mixture  of  both. 
If,  as  is  believed,  the  poisonous  material  aT)sorbed  from  the  bladder 
and  the  non-eliminated  urinary  salts  find  vent  through  the  aliment- 
ary canal,  we  have  no  trouble  in  discovering  a  cause  for  the  catar< 


OEGANIC  DISEASES   OP   THE  BLADDER.  YY7 

rlial  disorder.  The  nervous  disorders  are  readily  explained  by  the 
effects  of  the  abnormal  condition  of  the  blood,  and  the  broken  and 
sleepless  nights  which  interrupt  and  retard  the  nutrition  of  the 
nervous  system. 

The  bowels  are  usually  irregular  and  constipated,  and  require 
daily  enemata  to  open  them.  This  costiveness  is  occasionally  in- 
terrupted by  a  profuse  watery  diarrhoea,  which  would  seem  to  be 
an  effort  of  nature  to  relieve  the  blood  of  its  abnormal  contents,  as 
I  have  already  said.  It  may  last  for  days  or  for  only  a  iew  hours, 
and  the  discharges  are  usually  rich  in  the  carbonate  of  ammonia. 
The  septicteniic  diarrhoea  differs  usually  in  tlie  great  prostration  ac- 
companying it,  the  character  of  the  stools  (black  or  greenish  black, 
and  very  offensive,  the  organic  odor  quite  or  partly  hiding  the 
ammoniacal  odor),  and  the  fact  that  it  is  usually  preceded  or  accom- 
panied by  chills,  fever,  and  sweating.  If  checked  too  abruptly, 
head  symptoms,  mild  muttering  delirium,  etc.,  are  hkely  to  follow. 

The  results  of  imperfect  digestion  are  seen  in  the  poor,  un- 
healthy condition  of  the  patient's  flesh  and  skin,  and  all  the  signs  of 
malnutrition  present. 

(c)  The  Cutaneous  Surface. — The  skin  of  patients  with  chronic 
cystitis  is  usually  sallow,  loose,  and  has  a  lifeless  feel.  Indeed,  one 
might  ahnost  make  a  diagnosis  from  the  complexion  alone.  Sweat- 
ing of  the  palms  of  the  hands  and  soles  of  the  feet  is  common.  In 
low  states  of  the  system  the  patients  are  especially  liable  to  iiight- 
sweats.  The  perspiration  sometimes  has  a  urinous  odor.  I  have  al- 
ready spoken  of  the  septicaemie  diaphoresis. 

(d)  The  Wervous  System. — I  will  first  consider  the  symptoms 
appertaining  to  the  brain  and  its  function,  and  then  to  the  sub- 
cephalic  nervous  system. 

There  is  a  peculiar  brain  condition,  supposed  by  some  to  be 
caused  by  cerebral  anaemia  ;  others  attribute  it  to  a  peculiar  poison 
circulating  in  the  blood.  By  anaemia  of  the  brain  in  this  connec- 
tion is  meant  not  only  lack  of  blood  in  that  organ,  but  an  exceed- 
ingly impoverished  condition  of  the  blood  there  circulating.  Those 
remedies  that  tend  to  lessen  the  amount  of  blood  in  the  brain,  as 
bromide  of  potassium  and  ergot,  produce  most  unpleasant  symp- 
toms in  these  cases,  such  as  dizziness  and  fainting.  Medicines 
which  act  in  a  manner  to  congest  the  brain,  if  given  in  small  doses, 
improve  this  condition,  as  also  do  the  ferruginous  tonics,  especially 
iron  by  hydrogen.  From  this  it  would  appear  that  this  peculiar  con- 
dition is  due  more  to  the  amount  and  imperfect  constitution  of  the 
blood  circulating  in  the  brain,  than  to  the  absorbed  or  non-eliminated 


778  DISEASES  OF  WOMEN. 

urinary  matter.  Against  this  theory,  however,  is  the  fact  that  when 
the  vesical  tenesmus  is  least  and  the  urine  remains  in  the  bladder 
longest,  and  hence  the  blood-poisoning  is  presumably  the  greatest, 
the  weak  and  somnolent  feeling  is  the  worst.  Both  causes  probably 
act  to  produce  this  condition.  By  some,  however,  this  cerebral 
anpemia  is  attributed  partly  to  the  poor  blood  condition,  but  chiefly 
to  imperfect  circulation  due  to  want  of  exercise.  This  view  is 
supported  by  the  fact  that  digitalis  and  exercise  in  the  open  air 
greatly  improve  these  patients. 

When  septic  complications  arise  and  the  patient  becomes  very 
low,  or  when  the  septic  diarrhoea  is  checked  too  suddenly,  low,  mut- 
tering delirium  with  hallucinations  commonly  results.  This  has 
been  alluded  to  before.  The  mind  is  usually  markedly  affected, 
the  patients  feeling  "  blue,"  morose,  lacking  hope,  confidence,  and 
spirit.  At  times,  indeed,  they  become  so  despondent  as  to  seriously 
contemplate  suicide.  The  little  rest  that  they  get  at  night  is  often 
broken  by  horrible  dreams  and  nightmare.  I  am  now  speaking  of 
the  most  severe  cases. 

The  Bubcephalic  nervous  system  is  seldom  affected  beyond  oc- 
casional irregular  action  of  the  heart,  chills,  fever  and  sweating, 
and  occasional  neuralgia.  Pains  in  the  nipple,  abdomen,  arms,  legs, 
hands,  and  feet,  are  by  no  means  rare.  The  vesical  pain  has  already 
been  referred  to.  Of  course  all  these  symptoms  that  I  have  spoken 
of  as  accompanying  cystitis,  do  not  occur  in  each  case,  nor  are  the 
greater  part  of  them  peculiar  to  cystitis  alone.  I  now  pass  to  diag- 
nosis. 

Diagnosis. — The  diagnosis  of  cystitis  is  generally  easy  in 
marked  cases,  but  in  mild  attacks  care  is  necessary  to  distinguish  it 
from  other  conditions  that  cause  similar  symptoms. 

Frequent  urination  occurs  in  many  other  troubles,  such  as  pro- 
lapsus uteri,  adhesions  from  pelvic  peritonitis,  with  abdominal  tu- 
mors, and  in  various  neuroses.  Pregnancy,  also,  sometimes  gives  rise 
to  annoying  frecpiency  of  micturition.  Frequent  urination  from 
prolapsus  is  worse  when  the  patient  is  standing  or  walking,  and  is 
relieved  wholly,  or  to  a  great  extent,  by  the  recumbent  position ; 
while  in  cystitis,  position  makes  no  marked  difference. 

I  have  seen  one  very  interesting  exception  to  this  general  rule. 
The  patient  had  a  complete  prolapsus  for  many  years,  and  when  in 
the  erect  position  she  could  retain  the  urine  for  an  ordinary  length  of 
time,  but  when  she  was  reclining  the  most  urgent  desire  to  urinate 
came  on,  and  she  could  only  retain  a  very  small  quantity  of  urine. 
The  cause  of  this  I  found  to  be  inflammation  of  the  neck  of  the 


ORGANIC  DISEASES  OF   THE  BLADDER.  Y79 

bladder.  When  in  the  upright  position  the  urine  settled  down  in 
the  dependent  portion,  but  while  recumbent  the  pressure  came  on 
the  tender  part. 

In  adhesions  from  pelvic  peritonitis,  abdominal  tumors,  and 
pregnancy,  the  desire  to  urinate  only  comes  on  when  the  bladder  is 
partly  filled,  and  is  about  the  same  day  and  night.  Frequency  of 
urination  is  not  usually  accompanied  by  tenesmus,  except  when  due 
to  cystitis.  In  the  various  forms  of  vesical  neuroses  frequent  urina- 
tion is  very  irregular,  the  patient  at  times  being  almost  entirely  free 
from  it,  and  at  other  times  very  much  troubled. 

The  frequent  and  painful  urination  of  cystitis  may  be  simulated 
by  urethritis  and  other  painful,  irritable  conditions  of  the  urethra. 
The  distinction  can  be  made  usually,  from  the  fact  that  in  urethral 
disease  there  is  no  vesical  tenesmus,  or  if  any,  it  is  much  less  than 
in  cystitis.  There  are  acute  pain  in  the  act  of  urination,  and  a  burn- 
ing sensation  in  the  m-ethra,  which  sometimes  cause  sympathetic 
vesical  tenesmus ;  but  when  this  latter  passes  off  the  bladder  will 
tolerate  distention  to  the  fullest  extent. 

The  urine  should  be  carefully  examined  and  the  results  as  care- 
fully considered.  Implicit  dependence,  however,  must  not  be 
placed  on  the  condition  of  the  urine.  Acute  or  chronic  congestion 
may  produce  considerable  mucus  that  is  sometimes  mistaken  for  pus 
that  has  become  gelatinous  by  the  action  of  strong  alkali.  Pus  may 
be  present  in  the  urine  from  suppuration  of  the  upper  urinary  pas- 
sages (pyonephrosis,  renal  abscess,  and  pyelitis) ;  from  abscesses  of 
neighboring  organs  or  tissues  opening  into  the  bladder,  as  in  colitis 
and  pelvic  cellulitis.  When  there  is  doubt  on  this  point,  Sir  Henry 
Thompson's  method  of  procedure  as  recommended  by  Van  Buren 
and  Keyes  for  detecting  the  source  of  blood  should  be  tried. 

A  differential  diagnosis  between  cystitis  and  pyelitis,  by  means 
of  the  urine  alone,  is  almost  an  impossibility,  especially  in  the 
later  stages  of  the  former.  Thompson's  method,  the  endoscope, 
and  the  presence  or  absence  of  a  tumor  in  the  loins,  with  the  gen- 
eral symptoms,  must  be  the  guides.  No  dependence  can  be  placed 
on  the  epithelium,  as  transitional  forms  from  the  bladder,  as  already 
explained,  are  very  likely  to  be  mistaken  for  the  normal  epithelium 
of  tiie  renal  pelves,  and  lead  to  error. 

One  of  the  difficulties  that  long  perplexed  the  diagnostician  M'as 
to  ascertain  the  condition  of  the  kidneys  in  cases  of  cystitis.  The 
products  of  the  cystitis  made  the  analysis  of  the  urine  almost  use- 
less in  the  investigation  of  nephritic  diseases.  The  first  step  toward 
clearer  light  on  this  subject  was  taken  in  washing  the  bladder  clean 


780  DISEASES  OP  WOMEN. 

of  all  pus  and  mucus,  and  then  collecting  for  examination  the  urine 
first  secreted  after  the  washing.  This  was  a  great  help,  but  was  not 
fully  satisfactory  because  only  small  quantities  could  be  obtained  at 
a  time. 

I  succeeded  much  better  in  estimating  the  condition  of  the  kid- 
neys by  determining  the  quantity  of  urea  eliminated,  and  not  by  the 
presence  or  absence  of  albumin  or  casts.  It  is  only  necessary  to 
remove  the  products  of  the  cystitis  by  filtration  from  the  specimen 
of  urine  and  lind  out  in  the  usual  way  the  quantity  of  urea.  This 
method  of  investigation  gives  a  far  more  accurate  idea  of  the  state 
of  the  renal  function  than  the  finding  of  albumin  and  casts.  Again, 
by  estimating  in  this  way  the  degree  of  impairment  of  function  one 
obtains  an  idea  of  the  extent  of  organic  changes  that  liave  taken 
place  in  the  kidneys.  This  is  especially  reliable  if  the  impairment 
of  function  is  persistent.  There  is  an  exceptional  condition  in  which 
a  diagnosis  can  not  be  made  in  this  way,  and  that  is  when  one  kid- 
ney only  is  diseased.  Then  the  diagnosis  can  not  be  made  without 
the  use  of  tlie  ureteral  catheter.  In  fact  it  is  only  in  such  cases 
that  I  need  to  catheterize  the  ureters  for  diagnostic  purposes.  In 
all  other  conditions  of  the  kidneys  a  diagnosis  can  be  made  without 
resorting  to  physical  exploration  with  the  cystoscope,  endoscope,  or 
ureteral  catheter. 

To  make  a  positive  and  reliable  diagnosis,  resort  must  be  had  to 
physical  exjiloration  of  the  organ.  The  methods  of  exploration  are 
palpation,  percussion,  and  auscultation  of  the  abdomen  ;  examination 
of  all  the  pelvic  organs  by  the  touch  and  speculum  ;  and,  lastly,  ex- 
ploration of  the  bladder  by  the  catheter,  or  sound. 

By  palpation  and  percussion  of  the  abdomen  tenderness  and  dis- 
tention of  the  bladder  may  be  detected,  if  either  exists.  By  the 
same  means  it  may  be  ascertained  whether  the  bladder  is  contracted 
and  its  walls  thickened,  rigid,  or  relaxed. 

Auscultation  will  possibly  reveal  friction  sounds  in  cases  where 
inflammation  has  extended  to  the  serous  coat,  and  caused  roughen- 
ing by  exudation  on  the  peritoneal  surfaces.  These  may  seem  to 
be  rather  delicate  points  in  examination,  but  in  obscure  cases  we 
must  avail  ourselves  of  all  the  means  that  can  ffive  the  slightest 
evidence. 

Examination  of  the  pelvic  organs  by  touch  will  detect  an}'  dis- 
ease of  these  organs  that  may  either  cause  or  complicate  the  cystitis. 
Disj^lacements  and  inflammatory  affections  of  the  uterus,  vagina,  or 
rectum,  pelvic  peritonitis,  or  the  products  of  a  former  attack  of  that 
disease,  ovarian  diseases  and  tumors,  should  be  carefully  sought  for, 


ORGANIC   DISEASES   OP   THE   BLADDER.  Y81 

and,  if  present,  tlieir  relations  to  tlie  vesical  trouble  carefully 
studied. 

Cystitis  produced  by  or  producing  pelvic  cellulitis  and  perito- 
nitis has  the  same  symptoms  as  ordinary  purulent  vesical  inflam- 
mation, plus  those  of  well-defined  pelvic  inflammation.  There  are 
usually  pain  and  tenderness  of  the  pelvic  organs,  and  the  sympto- 
matic fever  of  local  inflammation. 

In  those  cases  where,  from  gluing  together  of  the  pelvic  organs, 
the  bladder  walls  are  separated  and  kept  upon  the  stretch,  inconti- 
nence often  results,  sometimes  overdistention  with  dribbling.  In 
such  cases  the  cystitis  may  be  entirely  secondary  to  the  pelvic  ad- 
hesions, and  consequent  vesical  distention.  The  urethra  should  be 
examined  with  care,  for  some  of  its  diseases  present  a  natural  his- 
tory closely  resembling  that  of  some  vesical  affections. 

By  a  careful  use  of  the  catheter  or  sound  introduced  into  the 
bladder,  the  degree  of  tenderness  of  that  organ  can  be  determined, 
and  the  presence  of  foreign  bodies,  such  as  a  stone  in  the  bladder, 
can  be  excluded.  The  sound  being  in  the  bladder,  the  finger  may 
be  introduced  into  the  vagina,  and  the  posterior  and  inferior  walls 
be  examined  as  to  their  thickness  and  tenderness. 

In  supposed  cystitis  the  neck  of  the  bladder  ought  always  to  be 
examined  with  a  view  of  detecting  ulceration  and  fissures  at  that 
point.  These  fissures  give  rise  to  symptoms  very  closely  simulating 
cystitis,  and  the  differential  diagnosis  can  only  be  made  by  the  en- 
doscope. 

The  endoscope  affords  the  only  means  of  ascertaining  the  exact 
appearance  of  the  interior  of  the  bladder.  The  extent  of  conges- 
tion, the  degree  and  extent  of  ulceration,  and  other  lesions  can  be 
observed  in  this  way,  and  this  instrument  should  be  used  in  all  cases 
where  the  diagnosis  is  doubtful,  or  when  the  case  does  not  yield  to 
supposed  proper  treatment.  The  chief  value  of  the  endoscope  is  in 
examining  the  urethra  and  neck  of  the  bladder.  When,  by  the  use 
of  this  instrument,  urethral  disease  can  be  excluded,  the  diagnosis 
of  cystitis  may  be  made  by  exclusion.  If  this  is  not  satisfactory, 
then  the  bladder  should  be  emptied,  washed,  and  thoroughly  cleaned 
of  all  inflammatory  products.  The  catheter  should  be  left  to  drain 
off  the  urine  as  fast  as  it  flows  into  the  bladder.  This  urine,  coming 
almost  directly  from  the  kidneys,  will  show  if  any  renal  disease  exists. 
Sometimes  the  bladder  is  too  irritated  to  permit  the  presence  of  the 
catheter ;  then  the  patient  should  urinate  as  soon  as  there  are  a  few 
drachms  secreted,  and,  if  there  should  be  any  evidence  of  renal  dis- 
ease, the  diagnosis  would  be  complete. 


Y82  DISEASES   OF   WOMEN. 

AVhen  from  an  examination  of  the  urine  or  the  symptoms  it  is 
impossible  to  tell  whether  disease  of  the  kidneys  complicates  the 
vesical  trouble,  recourse  may  be  had  to  the  ophthalmoscope,  by 
means  of  which  renal  disease,  retinitis  albuminurica,  may  often  be 
diagnosticated. 

Causation. — The  cause  of  acute  cystitis  may  for  convenience  be 
classed  under  five  heads,  each  of  which  will  be  studied  separately : 

1.  Direct  injuries,  such  as  blows  in  the  vesical  region,  falls,  frac- 
tures of  the  pelvic  bones,  violent  copulation,  sudden  urine  displace- 
ments and  pressure  therefrom,  contusions  and  injuries  during  labor, 
foreign  bodies,  rough  catheterization,  and  overdistention  from  reten- 
tion of  urine. 

2.  Abnormal  urine. 

3.  Inflammation  of  adjacent  organs. 

4.  Constitutional  diseases. 

5.  Drugs,  improper  food,  and  the  virus  of  gonorrhoea. 

These  causes  also  pertain  to  chronic  cystitis,  whether  it  begins  as 
an  acute  or  subacute  affection. 

1.  Direct  Injuries. — Blows  over  the  vesical  region,  falls,  and  espe- 
cially fracture  of  the  pelvic  bones,  caused  by  some  great  force,  usu- 
ally produce  acute  inflammation  of  the  bladder,  with  or  without 
rupture  of  that  organ.  The  bladder,  when  full,  is,  of  course,  more 
readily  ruptured  than  when  empty,  rupture  in  the  latter  condition 
being  almost  an  impossibility.  This  item  of  knowledge  can  be  turned 
to  practical  use  in  traveling,  either  by  rail  or  water,  by  remembering 
to  frequently  empty  the  bladder.  In  cystitis  from  severe  and  direct 
injury,  even  without  any  perceptible  traumatic  lesion  of  the  mucous 
membrane,  there  is  apt  to  be  marked  haemorrhage,  much  greater, 
indeed,  than  in  cystitis  from  other  causes. 

Sudden  displacement  of  other  pelvic  organs,  as  the  uterus,  may 
act  in  two  ways  :  First,  by  pressure  on  the  bladder,  or  by  dragging  it 
out  of  place  ;  second,  by  blocking  the  urethra  by  pressure.  These  dis- 
placements may  be  due  to  falls  or  blows,  and  it  is  not  an  uncommon 
occurrence  for  the  gravid  uterus  to  topple  over  by  its  own  weight. 
Supposing  a  retroversion  of  the  gravid  uterus,  the  cervix  would 
compress  the  urethra  against  the  pubes,  while  the  utero-vesical  liga- 
ment would  drag  the  upper  part  of  the  bladder  downward  and  back- 
ward. Even  after  the  uterus  has  been  replaced,  and  the  pressure  on 
the  urethra  removed,  with  relief  of  the  vesical  overdistention,  the 
retention  is  likely  to  persist,  and  overdistention  recur,  for  by  the 
pressure  the  urethra  becomes  much  tnmefled,  and  the  nniscular  and 
elastic  tissue  of  the  vesical  walls  overstretched  and  partly  paralyzeil. 


ORGANIC   DISEASES   OF   THE  BLADDER.  ^83 

If  the  distention  has  been  great  and  prolonged,  tliere  may  be  par- 
tial or  total  sloughing  of  the  vesical  mucous  membrane. 

In  retention  of  urine,  and  consequent  overdistention  of  the  blad- 
der during  or  after  labor,  from  either  injury  or  carelessness,  acute 
cystitis  is  very  apt  to  occur.  Here  injury  of  a  serious  nature  may 
be  done  to  the  urethra  by  pressure  against  the  pubic  bones  by  the 
child's  head,  with  or  without  the  intervening  soft  cushion  of  the 
anterior  uterine  lip.  This  is  especially  the  case  in  slow,  tedious 
labors,  where  the  pressure  is  almost  continuous. 

The  extent  to  which  the  bladder  may  be  distended  without  rup- 
turing is  quite  wonderful.  My  friend  Dr.  Bodkin  invited  me  to 
see  a  lady  with  him  in  consultation,  who  went  without  urination  for 
four  days  and  nights  after  her  confinement.  The  bladder  reached 
above  the  umbilicus,  and  contained  about  three  ordinary  pots-de- 
chambre  full  of  decomposed  urine,  which  was  drawn  off  by  the 
catheter.  The  bladder  remained  paralyzed  for  three  months  after- 
ward, but  finally  regained  its  expelling  power.  At  the  time  I  saw 
her  she  was  suffering  from  cystitis,  brought  on  by  the  maltreatment. 
In  justice  to  the  medical  profession  I  ought  to  say  that  this  lady  was 
attended  in  her  confinement  and  for  a  time  after  by  a  member  of 
the  so-called  new  school  of  medicine. 

The  ignorant  or  careless  use  of  instruments  during  delivery  is 
also  a  cause  of  serious  vesical  inflammation.  In  all  these  cases  the 
catheter  should  be  used  several  times  daily,  and  with  great  care, 
until  the  organ  has  regained  its  power,  and  the  contused  urethra 
fully  recovered  itself.  I  may  digress  here  long  enough  to  say  that 
the  soft-rubber  catheter  is  the  only  one  that  I  have  used  for  years. 
The  old  female  silver  catheter  is  the  most  dangerous  instrument  I 
have  ever  seen.  It  should  be  discarded  forever.  In  cases  where  the 
bladder  has  been  perfectly  healthy,  and  the  catheter  passed  a  num- 
ber of  times  by  way  of  experiment,  the  points  of  membrane  with 
which  the  instrument  had  come  in  contact  were  abraded  and  con- 
gested, thus  showing  the  danger  attending  the  unskillful  use  of  this 
instrument.  If  the  frequent  introduction  of  the  instrument  into  a 
healthy  bladder  produces  these  results,  how  easily  must  the  bladder 
of  a  pregnant  woman  be  inflamed  under  such  treatment,  for  the 
organ  has  been  for  a  time  more  or  less  congested,  and  during  labor 
perhaps  severely  bruised ! 

The  question  has  been  raised  as  to  whether  the  irritation  and  in- 
flammation following  catheterization  in  some  cases  is  not  due  to  the 
introduction  (during  manipulation)  of  air,  either  pure  or  containing 
germs  that  will  cause  decomposition  of  the  urine.     The  experiments 


Y84  DISEASES   OF   WOMEN". 

of  P.  Dubelt,  in  which  the  air  was  injected  into  the  bladder,  show 
that  it  is  perfectly  harmless.  Moreover,  the  same  experimenter 
found  that  the  injection  of  decomposing  urine  into  the  bladder  did 
little  or  no  harm  unless  the  mucous  surface  was  abraded.  What- 
ever may  be  the  effect  of  such  things  on  a  health}'  bladder,  I  do  not 
doubt  but  that  the  introduction  of  germs  by  means  of  air  or  a  dirty 
catheter,  decomposing  urine,  or  the  rough  or  too  frequent  use  of  a 
catheter,  would  produce  an  acute  exacerbation  in  an  organ  already 
diseased. 

The  influence  of  decomposed  or  decomposing  urine  in  producing 
inflammation  of  the  bladder  will  be  more  fully  spoken  of  again. 

Forcible  and  excessive  copulation  is  a  decided  exciting,  as  well 
as  predisposing,  cause  of  acute  or  subacute  cystitis,  and,  if  persisted 
in,  a  chronic  inflammation  of  the  bladder  is  usually  the  result. 

Foreign  bodies  in  the  bladder,  such  as  pieces  of  wood,  pins, 
needles,  hair-pins,  bodkins,  and  the  like,  that  are  sometimes  slipped 
in  by  hysterical  girls  and  those  who  masturbate,  excite  acute  inflam- 
mation if  not  speedily  removed. 

2.  Abnormal  Urine. — No  known  abnormality  of  the  urine  will,  I 
think,  excite  acute  inflammation  in  a  perfectly  healthy  bladder.  In 
a  bladder,  however,  that  is  suffering  from  chronic  congestion  ;  in 
one  whose  walls  bear  deposits  of  tubercle ;  in  cases  where  some 
slight  degree  of  inflammation  already  exists,  then  abnormal  urine 
may  and  does  give  rise  to  marked  inflammatory  trouble.  As  a  rule, 
however,  inflammatory  vesical  disease  precedes  urine  decomposition. 
In  cystitis  following  overdistention,  the  retained  urine,  being  mixed 
with  mucus  thrown  out  by  the  irritated  and  tense  mucous  mem- 
brane to  shield  ioelf,  rapidly  decomposes,  and  still  further  aggra- 
vates the  abnormal  condition  of  the  membrane. 

"Women,  sometimes  from  abnormal  modesty,  more  often  from 
the  lack  of  opportunity,  retain  their  urine  until  the  bladder  is  dis- 
tressingly overdistended,  and  the  urine  partially  decomposed.  Of 
course  this  is  wrong  and  can  generally  be  avoided,  but  is  neverthe- 
less a  frequent  cause  of  disease  of  this  organ. 

Where  there  is  considerable  suppuration  of  the  upper  urinary 
passages  (renal  abscess,  pyelitis,  or  pyonephrosis),  the  acid  urine, 
loaded  with  pus,  has,  or  seems  to  have,  an  irritating  effect  on  the 
vesical  mucous  membrane,  and  in  some  instances  probably  lights  up 
a  cystitis,  and  certainly  aggravates  one  when  already  existing. 

Deposits  of  the  amorphous  phosphate  of  lime,  or  of  the  ammonio- 
magnesian  phosphate,  often  greatly  aggravate  and  render  serious  a 
previously  mild  cystitis,  but  seldom  if  ever  produce  acute  inflamma- 


ORGANIC   DISEASES   OP  THE   BLADDER.  7S5 

tion  in  a  healthy  bladder.  This  raay  be  said  also  of  uric-acid  gravel 
and  other  crystalline  urinary  sediments,  they  being  at  most  only  able 
to  produce  some  hyperaemia  of  the  membrane  with  a  little  excess  of 
the  mucous  secretion. 

Urine  which  is  already  decomposed,  or  decomposing,  as  I  have 
already  said,  can  produce  acute  cystitis  only  in  an  already  diseased 
bladder,  or  in  one  where  abrasions  of  the  epithelial  surface  exist. 

To  show  how  some  of  these  causes  may  combine  to  produce  cys- 
titis, let  me  take,  for  example,  the  bladder  of  a  pregnant  woman 
which  has  for  some  time  shared  congestion  with  the  other  pelvic 
organs.  Retention  and  some  distention  of  the  bladder  occur  from 
some  cause ;  a  clumsy  physician  attempts  to  pass  a  metallic  catheter, 
and  does  it  roughly  and  rapidly,  and  relieves  the  viscus  of  its  con- 
tents. A  slight  catarrh  of  the  mucous  membrane,  the  surface  of 
which  is  somewhat  abraded,  ensues.  By  the  catalytic  action  of  the 
mucus  present  in  it,  the  urine  is  rapidly  decomposed.  The  decom- 
position is  often  aided  by  germs  introduced  with  the  catheter.  Car- 
bonate of  ammonia,  being  set  free  from  the  broken-down  urea,  as- 
sists in  alkalizing  the  fluid,  precipitating  the  amorphous  phosphates 
thereby,  and  forming,  with  the  phosphate  of  magnesia  already  pres- 
ent, the  ammonio-magnesian,  or  triple  phosphate.  The  urine  is 
further  alkalized  by  the  alkali  of  the  mucus.  The  bladder-walls  not 
having  fully  regained  their  tone,  a  little  decomposed  urine  remains 
after  each  micturition,  and  aids  in  decomposing  that  which  is  next 
secreted,  and  would  otherwise  be  normal.  The  mucus  increases  in 
amount,  the  ammonia  is  more  rapidly  set  free,  and  the  mucous 
membrane  more  and  more  irritated,  until  a  true  acute  cystitis  is  set 
up.     Such  cases  are  of  almost  daily  occurrence. 

The  decomposed  urine  alone,  however,  produced  without  the 
overdistention  or  without  the  abrasion  would  not  have  occasioned 
a  true  acute  cystitis,  but  might  possibly  by  slow  gradations  have 
worked  up  a  subacute  cystitis.  The  rule,  if  it  may  be  called  such, 
is  the  one  that  I  have  already  given — viz.,  that  some  abnormality  of 
the  urinary  organs  (as  catarrh)  almost  invariably  precedes  urinary 
decomposition. 

3.  Inflammation  of  Adjacent  Organs. — Acute  cystitis  may  arise 
from  the  extension  of  inflammation  from  neighboring  organs,  as  in 
vaginitis,  metritis,  uterine  and  vaginal  cancer,  extra-uterine  preg- 
nancy, abscesses  of  the  colon  or  other  organs  opening  into  the  blad- 
ber,  pelvic  peritonitis,  cellulitis,  etc.  Gonorrhoeal  inflammation  of 
the  urethra  may  extend  to  the  bladder.  As  gonorrluiea  of  the  female 
urethra  is  comparatively  rare,  such  an  extension  is  seldom  seen. 
51 


786  DISEASES  OF  WOMEN. 

When  it  does  invade  the  urethra  it  is  very  apt  also  to  extend  to  the 
bladder,  and  is  very  severe.  Intlanimation  of  the  renal  pelves  and 
ureters  may  extend  to  this  organ  and  cause  cystitis,  the  usual  course, 
however,  being  from  the  bladder  to  the  ureters  and  the  kidneys. 

4.  Certain  diseases  of  the  general  system  affect  the  bladder,  such 
as  the  eruptive  fevers.  In  scarlet  fever,  and  measles  especially,  I 
have  noticed  that  the  mucous  membrane  of  the  bladder  suffers,  to 
some  extent,  like  the  mucous  and  tegumentary  tissues  elsewhere. 
Diseases  of  the  heart  and  liver  act  more  as  predisposing  causes,  by 
producing  chronic  vesical  congestion,  than  as  exciting  causes,  and 
when  they  do  produce  cystitis  it  is  usually  of  a  low  chronic  type. 
Old  age,  when  the  has  fond  is  greatly  deepened,  acts  more  as  a  pre- 
disposing cause,  by  allowing  the  collection  and  decomposition  of 
urine.  Paraplegia  and  other  affections  of  like  nature,  by  allowing 
overdistention  and  decomposition,  as  a  rule,  produce  cystitis,  but  of 
a  low  form. 

5.  Drugs,  Improper  Foods,  and  the  Virus  of  Gonorrhoea. — Of  all 
drugs,  cantharides  is  undoubtedly  the  most  active  in  producing  true 
acute  cystitis.  In  many  cases  it  produces  simple  irritation  and  hy- 
peraemia,  stopping  short  of  actual  inflammation.  Arsenic  and  tur- 
pentine also  produce  irritation  and  active  hyper^emia,  but  seldom  if 
ever  go  further. 

Alcoholic  beverages  persisted  in  for  a  length  of  time  act  more  as 
predisposing  than  as  exciting  causes.  They  may,  however,  produce 
a  low  grade  of  cystitis,  or,  like  the  medicines  given  above,  light  up 
an  acute  process  in  an  already  diseased  vesical  membrane.  Dr.  A. 
Jacobi  has  seen  aggravated  cases  of  cystitis  caused  by  the  free  and 
long-continued  use  of  large  doses  of  the  chlorate  of  potassa. 

The  various  foods  can  not  produce  acute  cystitis  in  a  healthy 
bladder,  but  may  aggravate  an  already  diseased  condition.  The  pro- 
hibition, therefore,  of  stimulating  condiments,  alcohol,  asparagus, 
and  onions  in  these  diseases  will  at  once  suggest  itself.  I  have  al- 
ready spoken  of  gonorrhoea  as  a  cause  of  cystitis,  and  need  not  dwell 
on  it  here. 

M.  Eugene  Monod  (^' Annales  de  Gynecol.,"  May,  1S80),  in 
discussiug  the  question  of  cystitis,  presents  the  following  con- 
clusions : 

1.  The  urinary  symptoms  incident  to  pregnancy  proceed  from 
two  different  canines,  to  each  of  which  there  corresponds  a  distinct 
clinical  group  of  symptoms.  The  first  group  receives  its  explana- 
tion from  the  pressure  produced  by  the  gravid  uterus,  which  leads 
to  retention  of  urine.     The  second  is  caused  by  vesical  congestion 


ORGANIC  DISEASES  OP  THE  BLADDER.  787 

which  results  from  the  predisposition  of  the  bladder  to  inflamma- 
tion, owing  to  its  close  vascular  connection  with  the  uterus. 

2.  During  the  first  weeks  of  utero-gestation  there  may  occur  a 
variety  of  acute  cystitis  which  is  unquestionably  caused  by  the  de- 
velopment of  pregnancy. 

3.  Immediately  after,  or  during  the  first  weeks  following  normal 
delivery,  there  may  arise  a  variety  of  cystitis  which,  owing  to  the 
time  of  its  appearance,  deserves  to  be  called  post-puerperal  cystitis, 

■J:.  The  anatomical  relations  between  uterus  and  bladder,  as  well 
as  their  vascular  interconnections,  account  for  the  frequency  of  ves- 
ical disorders  accompanying  many  uterine  maladies.  Certain  physio- 
logical changes  of  the  bladder  during  menstruation,  and  at  the  time 
of  the  menopause,  also  influence  the  establishment  of  bladder  troubles. 
Thus  there  is  seen  to  exist  a  whole  class  of  vesical  inflammations  be- 
longing only  to  women,  and,  contrary  to  the  generally  accepted  opin- 
ion, cystitis  is  by  no  means  rare  in  women. 


CHAPTER  XLIII. 

OKGAJS'IC   DISEASES    OF   THE   BLADDER    (CONTINUED). 

TREATMENT    OF    CYSTITIS  —  CROUPOUS    AND    DIPHTHERITIC 
CYSTITIS— CYSTITIS    WITH    EPIDERMOID    CONCRETIONS. 

Cystitis  requires  both  local  and  constitutional  treatment,  and 
withal  it  is  a  troublesome  disease  to  manage,  especially  in  its  chronic 
form.  The  constitutional  treatment  consists,  first  of  all,  in  so  regu- 
lating the  character  of  the  urine  that  it  shall  be  unirritating  to  the 
diseased  organ.  Pain  and  vesical  tenesmus  should  be  relieved  if 
possible.  The  skin  should  be  kept  in  a  healthy  and  active  condi- 
tion and  the  bowels  regular  and  free,  in  order  to  prevent  all  strain- 
ing at  stool  and  secure  free  action  of  the  portal  circulation.  Free 
elimination  by  the  skin  and  bowels  will  give  the  kidneys  and  blad- 
der less  to  do.  To  overcome  existing  constipation,  saline  laxatives 
should  be  used.  A  glass  of  purgative  mineral  water,  given  an  hour 
before  breakfast,  answers  very  well  in  most  cases.  Cold-water  ene- 
mata  are  advised  by  good  authorities. 

Winckel  recommends  the  use  of  saline  laxatives,  pushed  to  a 
point  where  intestinal  hypersemia  is  produced  and  maintained  for  a 
time.  He  believes  that  the  blood  may,  in  this  manner,  be  to  a  cer- 
tain extent  diverted  from  the  bladder ;  and  I  am  of  the  belief  that 
the  practice  is  a  sound  one.  A  case  of  my  own  is  of  interest  as 
showing  the  benefit  effected  (supposably)  in  this  way.  A  lady  had 
cataiTli  of  the  bladder  of  some  months'  standing,  which  I  had  been 
treating  in  the  usual  way,  with  only  slight  benefit.  She  was  one 
day  attacked  with  cholera  morbus  with  serous  purging  and  vomiting, 
the  former  almost  as  severe  as  that  of  Asiatic  cholera.  The  effect, 
for  a  time  was  to  almost  suspend  the  action  of  the  kidneys.  AV^hen 
she  recovered,  she  was  delighted  to  find  that  her  cystitis  had  left  her. 

Among  the  conditions  which  produce  irritating  urine,  and  hence 
tend  to  produce  cystitis  or  to  aggravate  it  if  it  already  exists,  are 
malnutrition  from  any  cause  and  the  strumous,  gouty,  and  rheu- 
matic diatheses.     When  either  of   these  is   present   it  should  be 


ORGANIC  DISEASES   OF  THE  BLADDER.  789 

treated  for  the  general  good  of  the  patient  and  the  indirect  effect 
upon  the  bladder. 

The  diet  of  patients  suffering  from  this  disease  must  be  care- 
fully regulated.  Milk  will  be  found  to  agree  excellently  in  most 
cases.  In  the  hands  of  Dr.  George  Johnson,  of  England,  an  exclu- 
sive milk  diet  has  cured  several  cases,  some  of  great  severity  and 
long  standing. 

He  says :  "  The  milk  may  be  taken  cold  or  tepid  and  not  more 
than  a  pint  at  a  time,  lest  a  large  mass  of  curd,  dilBcult  of  digestion, 
form  and  collect  in  the  stomach.  Some  adults  will  take  as  much  as 
a  gallon  in  the  twenty-four  hours.  With  some  persons  the  milk  is 
found  to  agree  better  after  it  has  been  boiled,  and  then  taken  either 
cold  or  tepid.  If  the  milk  be  rich  in  cream,  and  if  the  cream  disa- 
gree, causing  heartburn,  headache,  diarrhoea,  or  the  symptoms  of 
dyspepsia,  the  cream  may  be  partially  removed  by  skimming. 
Constipation,  which  is  one  of  the  most  frequent  and  troublesome  re- 
sults of  ail  exclusively  milk  diet,  is  to  some  extent  obviated  by  the 
cream  in  the  unskimmed  milk.  When  the  vesical  irritation  and  ca- 
tarrh have  passed  away,  solid  food  may  be  combined  with  the  milk, 
and  a  gradual  return  made  to  the  ordinary  diet." 

I  have  tried  this  method  of  treatment  in  several  instances  with 
decided  benefit. 

I  may  briefly  state  that  the  bill  of  fare  usually  given  consists 
largely  of  fluid  foods,  as  milk,  yolk  of  egg,  soups,  and  beef  essence. 
Lean  meat  in  small  amount,  and  other  solid  or  semi-solid  foods  that 
are  easily  digested  and  nutritious,  may  also  be  allowed.  The  cause, 
whatever  it  may  be,  should  be  removed,  if  possible  ;  and  the  reme- 
dies must  be  adapted  to  the  stage  and  condition  of  the  inflammation. 
In  the  acute  stage  aggravated  by  exposure  to  cold,  diaphoretics 
should  be  freely  used,  and  the  patient  made  to  rest  as  quietly  as  pos- 
sible. Diuretics  should  be  given  if  the  urine  is  loaded  with  solid 
material,  and  the  alkahne  salts  are  to  be  preferred.  Yichy  water 
or  flaxseed  tea  with  citrate  or  nitrate  of  potash,  wiU  answer  very 
well  at  the  beginning  of  the  treatment.  In  using  such  salines,  it 
serves  admirably  to  give  them  in  an  infusion  of  buchu  in  case  the 
patient's  stomach  does  not  rebel  at  the  taste  of  it.  This  of  itself  is 
a  most  valuable  remedy  in  almost  all  bladder  affections.  Care  must 
be  taken,  however,  not  to  push  diuretics  too  far.  Sufficient  to  bring 
the  urine  to  its  normal  proportions,  and  make  it  slightly  alkaline  if 
naturally  acid,  is  all  that  is  required. 

In  the  early  stages  of  acute  cystitis,  as  well  as  in  irritable  blad- 
der, Sidney  Kinger  and  other  authorities  strongly  commend  the  use 


790  DISEASES  OF   WOMEN, 

of  minim  doses  of  tincture  of  cantbarides  repeated  every  hour,  and 
even  often er,  but  I  have  not  seen  very  good  eifects  from  its  use  in 
cystitis. 

One  or  two  leeches  to  the  anterior  vaginal  wall  may  be  tried, 
and  hot  applications  to  the  epigastrium  in  acute  cases.  To  relieve 
pain,  opium  is  indicated.  Dover's  powder  is  very  valuable,  and 
may  be  given  with  ordinary  doses  of  camphor.  If  there  is  any  ob- 
jection to  anodynes  given  in  this  way,  or  if  there  is  sympathetic 
rectal  tenesmus,  suppositories  of  morphia  and  belladonna  should  be 
used. 

While  I  have  said  that  opium  may  be  used  at  the  onset  of  acute 
cases,  and  to  relieve  the  suffering  in  old  cases  that  can  not  be  cured, 
I  must  impress  upon  the  mind  the  great  harm  that  may  come  from 
the  injudicious  use  of  this  drug  in  cystitis.  It  deranges  the  digestive 
organs  and  the  secretions  generally,  especially  that  of  the  kidneys ; 
and,  by  changing  the  quantitative  composition  of  the  urine,  renders 
it  irritating  to  the  bladder. 

In  some  cases,  where  frequent  urination  and  tenesmus  are  very 
severe,  owing  to  excessive  nervous  irritability,  twenty-grain  doses  of 
the  bromide  of  potassium,  every  four  hours  until  relieved,  act  very 
nicely  ;  indeed,  this  succeeds  in  cases  where  opiates  fail  entirely. 
Recently  I  have  used  hydrobromic  acid  and  lind  that  it  acts  even 
better  than  the  bromide  of  potassium  in  some  cases. 

The  comparatively  new  drug,  eucalyptus  globulus,  is  worthy  of 
a  trial  in  obstinate  cases.  From  its  well-marked  beneficial  action  in 
albuminuria  and  other  affections  of  the  urinary  tract,  Dr.  W.  Ander- 
son was  led  to  try  it  in  cystitis,  and  he  reports  it  as  decidedly  useful. 
Dr.  J.  J.  Mulheron,  of  Detroit,  gives  it  in  doses  of  twenty  minims  in 
subacute  cystitis  with  good  results.  As  this  remedy  has  tonic, 
antiperiodic,  and  antiseptic  properties,  it  might  be  especially  suit- 
able in  malarious  districts.  An  infusion  for  injection  in  cases  where 
the  urine  was  decomposed,  would  most  probably  give  good  results. 

Benzoic  acid  is  perhaps  the  dnig  that  would  be  found  most  use- 
ful in  the  largest  number  of  cases.  It  often  seems  to  act  like  a  spe- 
cific, giving  speedy  and  permanent  relief.  It  may  be  given  in  about 
ten-grain  doses,  in  infusion  of  buchu,  three  or  four  times  a  day.  As 
the  acid  is  sparingly  soluble  in  cold  water,  an  equal  proportion  of 
borax  may  be  added  to  the  mixture.  To  insure  a  perfect  solution, 
one  may  prescribe  the  l)enzoate  of  ammonia,  which  in  the  same  dose 
acts  admirably,  and  is  more  palatable. 

In  the  more  advanced  stages  of  the  disease  remedies  are  used  for 
tiieir  direct  effect  upon  the  mucous  membrane,  and  much  good  is 


ORGANIC   DISEASES   OF   THE   BLADDER.  791 

obtained  in  this  way.  The  drugs  which  have  the  best  reputation  in 
urethritis  are  employed  in  cystitis.  Balsam  of  Peru  and  of  copaiba, 
oil  of  turpentine,  and  tar-water  are  the  most  important  of  this  class, 
and  should  be  given  in  capsules  in  the  same  way  as  for  gonorrhoea. 
Oil  of  sandal-wood  is  also  valuable  in  chronic  cases. 

When  the  pain  is  not  severe,  and  the  urine  is  loaded  with  mucus 
and  pus,  astringents  should  be  given.  Tannin  continued  for  a  con- 
siderable time  is  of  very  great  value.  Decoction  of  uva  ursi,  in 
half-ounce  doses,  may  also  be  used  for  this  purpose.  In  place  of 
tliese,  I  have  employed,  with  occasional  good  effect,  a  mixture  com- 
posed of  two  ounces  fluid  extract  of  buchu,  one  ounce  tincture  of 
conium,  and  one  grain  and  a  half  sulphate  of  morphia,  giving  tea- 
spoonful  doses  every  three  or  four  hours.  When  pain  is  not  severe, 
the  morphine  should  be  omitted. 

Dr.  B.  A.  Segur,  of  this  city,  has  used  salicylate  of  soda  in  puru- 
lent cystitis,  and  found  that  the  quantity  of  pus  in  the  urine  rapidly 
decreased  under  the  use  of  this  remedy. 

Dr.  Sansom,  of  London,  found  that  the  administration  of  carbolic 
acid  and  the  sulpho-carbolates  to  animals  prevented  the  decomposi- 
tion of  urine,  although  he  could  not  detect  any  of  the  salt  in  the 
secretion.  He  gave  the  sulj)ho-carbolates,  and  afterward  collected 
and  preserved  the  urine,  whicb  after  six  months  had  not  decomposed. 
This  fact  should  be  kept  in  mind,  and  turned  to  account  in  cases 
where  there  is  a  tendency  to  decomposition  from  retention  or  other 
causes. 

An  English  physician  reports,  in  the  "  Canadian  Practitioner," 
that  he  has  met  with  no  case  of  offensive  urine  (intestinal -vesical 
fistula  excepted)  that  ten  or  twenty  grains  of  boracic  acid  given  every 
three  hours  would  not  cure.  All  these  remedies  may  be  tried  in 
cases  that  are  seen  early ;  but,  when  they  fail,  or  when  the  acute 
stage  of  the  trouble  is  long  past  before  advice  is  sought,  then  local 
treatment  must  be  employed.  The  bladder  should  be  washed  out, 
and  medicated  injections  used.  This  every  surgeon  will  feel  com- 
petent to  do,  no  doubt,  but  I  must  give  some  general  directions  as 
to  the  methods  of  manipulating,  as  I  feel  assured  that  much  of  the 
good  which  ought  to  come  from  this  kind  of  treatment  is  lost,  and 
harm  done  instead,  by  not  clearly  knowing  bow  to  perform  this  op- 
eration, which  I  consider  both  difiicult  and  very  important. 

There  are  certain  rules  which  ought  to  be  carefully  observed  in 
washing  out  the  bladder.  The  catheter  should  be  sufficiently  soft 
and  flexible  to  be  incapable  of  injuring  the  bladder  or  urethra ;  it 
should  be  surgically  clean  ;  the  bladder  should  be  emptied  slowly, 


792  DISEASES  OF   WOMEN. 

especially  when  withdrawing  the  last  of  its  contents,  otherwise  the 
bladder  will  contract  abruptly  upon  the  catheter,  and  be  injured 
thereby ;  instillations  should  be  made  very  slowly  (the  bladder  can 
not  be  rapidly  distended  without  injury),  and  the  quantity  used 
should  not  be  more  than  the  patient  can  tolerate  without  pain.  An 
ounce  is  sufficient,  and  much  less  will  suffice  if  more  gives  pain. 
When  the  quantity  which  can  be  borne  is  determined,  the  instillation 
and  withdrawal  of  that  quantity  can  be  repeated  until  the  desired 
effect  is  obtained. 

By  carefully  following  these  rules,  the  possible  benefit  of  local 
treatment  can  be  obtained.  Neglect  of  these  will  certainly  bring 
disfavor  upon  the  method.  Some  years  ago  I  employed  a  rather 
complicated  arrangement  for  washing  out  the  bladder,  consisting  of 
a  reflux  catheter  with  a  fountain  attachment.  It  was  the  best  that 
I  could  find  at  that  time,  but  I  have  long  ago  discarded  it  for  a  sim- 
pler and  much  better  instrument.  I  use  now  a  soft-rubber  catheter, 
having  attached  to  it  a  piece  of  rubber  tubing,  these  being  joined 
by  a  piece  of  glass  tubing,  the  whole  being  about  two  feet  in  length. 

A  small  glass  funnel  is 
introduced  into  the  end 
of  the  rubber  tube,  and 
this  completes  the  instru- 
ment (Fig.  260). 

This  is  used  as  a  cathe- 
ter to  empty  the  bladder 
of  urine,  and  then,  leav- 
ing it  still  in  place,  the 
wasliing  out  is  accom- 
plished by  pouring  the  so- 
lution to  be  used  into  the 
funnel,  and  raising  it  high 
enough  to  make  it  flow  into  the  bladder.  The  funnel  is  then  lowered 
to  permit  the  fluid  to  escape,  and  the  process  is  repeated  as  often  as 
may  be  necessary.  Any  desired  quantity  of  fluid  can  be  instilled  into 
the  bladder  at  any  degree  of  pressure  that  may  be  necessary  for  the 
comfort  of  the  patient,  and  the  fluid  can  be  drawn  off  slowly  or  rap- 
idly by  elevating  or  depressing  the  funnel.  It  is  very  important  not 
to  let  air  ^nter  the  bladder,  and  this  can  l)e  accomplished  by  letting 
the  patient  retain  a  few  drachms  of  urine  before  beginning  the 
treatment.  When  the  catheter  is  introduced,  and  the  urine  in  the 
bladder  drawn  off",  enough  of  the  urine  will  remain  in  the  catheter  to 
till  it,  and,  by  filling  the  funnel  before  elevating,  the  fluid  used  will 


Fig.  260.  — Fountain-syringe  for  washing  bladder. 


OEGANIO  DISEASES  OF  THE   BLADDER.  793 

meet  the  urine  in  the  catheter  and  exclude  the  air.  In  case  the  blad- 
der is  empty,  the  catheter  should  be  filled  before  introducing  it  into 
the  urethra,  and  the  air  will  be  excluded  in  that  way.  When  once 
the  process  of  washing  is  begun,  the  exclusion  of  air  is  easily  man- 
aged by  regulating  the  elevations  and  depressions  of  the  funnel,  so 
that  the  catheter  and  tube  will  be  kept  full  all  the  time. 

This  instrument  fulfills  all  the  indications  perfectly,  and  very 
little  practice  is  necessary  to  enable  one  to  use  it  with  facility.  When 
the  bladder  has  been  thoroughly  cleansed  in  this  way  of  all  inflam- 
matory products,  medicated  applications  may  be  made  in  the  same 
manner.  The  quantity  of  fluid  instilled,  the  length  of  time  it  is  left 
in  the  bladder,  and  the  time  occupied  in  making  the  instillation  and 
withdrawing  it  can  all  be  regulated  according  to  the  will  of  the  sur- 
geon and  the  toleration  of  the  patient. 

Much  care  should  be  taken  in  lubricating  the  catheter  so  that  it 
can  be  introduced  readily.  Oil  has  been  used  for  this  purpose, 
and  I  believe  that  some  surgeons  use  it  still.  Castile  soap  and  water 
or  vaseline  answers  much  better.  The  oil  decomposes,  and  renders 
the  catheter  unclean  unless  great  care  is  taken  to  wash  and  disinfect 
the  instrument  very  thoroughly.  In  fact,  it  is  hardly  possible  to 
keep  a  catheter  clean  for  any  length  of  time  if  oil  is  used  as  a  lubri- 
cant. Vaseline  is  best,  and,  if  that  is  not  at  hand,  then  soap  will  an- 
swer. Cleansing  the  catheter  after  use  requires  more  than  a  passing 
notice.  I  have  found  that  if  a  soft-rubber  catheter  is  simply  washed 
after  use  in  the  ordinary  way — i.  e.,  by  washing  it  off  with  warm 
water,  and  then  rinsing  it  in  a  mild  solution  of  carbolic  acid — say 
five  per  cent — it  becomes  very  foul.  A  catheter  used  in  that  way 
for  a  few  days  will  be  found  swarming  with  bacteria  on  the  inside. 
Such  an  instrument  is  dangerous,  and  should  never  be  used.  In  my 
private  hospital  each  patient  has  a  catheter  for  herself  alone,  and, 
when  she  is  through  with  it,  it  is  destroyed.  After  each  time  that  a 
catheter  is  used  it  is  well  washed  in  hot  water,  and  then  kept  in  a 
ten-per-cent  solution  of  carbolic  acid,  and  once  in  every  twenty-four 
hours  it  is  kept  for  fifteen  or  twenty  minutes  in  boiling  water.  With 
all  this  care  the  catheter  can  be  kept  clean  and  safe  for  use. 

Simply  washing  out  the  bladder  is  often  beneficial,  and  ought  to 
be  repeated  frequently.  It  should  always  be  done  before  using  any 
medicated  application.  Warm  water  alone  is  usually  employed,  but 
the  addition  of  chlorate  of  potash  or  common  salt  makes  it  less  h-ri- 
tating  to  the  bladder.  I  prefer  borax  or  common  table-salt,  using 
about  sixty  grains  to  the  pint  of  water.  It  is  generally  conceded 
that  salt  and  water  are  more  acceptable  to  serous  and  mucous  mem- 


794  DISEASES   OF    WOMEN. 

branes  than  any  other  fluid,  because  more  like  the  normal  secretion 
of  these  parts ;  but  I  have  not  found  it  any  better,  if  as  good,  as 
borax.  AVhen  there  is  ulceration  or  suppuration,  carbolic  acid  and 
water  make  a  most  valuable  wash.  A  drop  to  tlie  drachm  or  there- 
about is  the  proper  proportion. 

Having  prepared  the  bladder  for  local  applications  by  carefully 
washing  it  out,  the  material  to  be  used  may  be  selected  from  a  long 
list  of  remedies.  I  shall  mention  only  a  few — those  which  I  believe 
to  be  the  most  valuable.  I  need  hardly  say  that  anodynes  have  been 
tried  most  faithfully.  The  painful  cliaracter  of  the  disease  suggests 
their  use,  but  they  are  neither  reliable  nor  very  eifectual.  The 
mucous  membrane  of  the  bladder  is  not  intended  to  absorb,  and, 
therefore,  very  little  of  the  anodyne  effect  of  opium,  or  any  of  its 
preparations,  is  obtained  when  injected,  even  when  the  dose  is  very 
large.  Should  there  be  ulceration,  then  the  local  and  constitutional 
effects  of  morphia  will  be  produced  by  absorption.  Braxton  Hicks 
uses  one  or  two  grains  of  morphia  to  the  ounce  of  water  as  an  in- 
jection, allowing  the  patient  to  retain  it  as  long  as  possible,  and 
claims  good  results  from  its  use.  Remedies  which  produce  local 
anaesthesia  do  relieve  the  pain  to  some  extent,  but  not  altogether, 
by  any  anodyne  action,  such  as  we  get  from  opium  given  by  the 
mouth  or  rectum.  Cocaine  relieves  the  pain  for  a  short  time,  but 
not  long.  Its  chief  value  is  to  benumb  the  parts  so  that  curative 
applications  may  be  more  easily  made.  In  some  cases  it  acts  as 
an  irritant.  Chloral  hydrate  is  recommended  to  relieve  the  ])ain.  I 
have  used  it  in  solution,  ten  to  fifteen  grains  to  an  ounce  of  water, 
and  found  benefit  from  it. 

The  astringent  and  alterative  injections  most  beneficial  and  most 
commonly  used  are  nitrate  of  silver,  sulphate  of  zinc,  tannic  acid, 
and  acetate  of  lead.  My  rule  is  to  use  one  or  two  grains  of  either 
to  the  ounce  of  warm  water,  and  to  increase  the  quantity  if  no  good 
effect  comes  from  the  small  doses,  but  to  carefully  avoid  injections 
strong  enough  to  cause  much  pain.  Chlorate  of  potash  is  valuable, 
and  perchloride  of  iron  is  said  to  be  useful.  Infusion  of  hydrastis 
Canadensis  has  been  used,  and  great  virtue  is  claimed  for  it.  I  have 
tried  it,  and  believe  that  it  acts  well  in  some  cases,  but  still  it  fails, 
like  the  rest,  in  others.  When  the  urine  is  alkaline  and  offensive 
from  long  retention,  which  is  occasionally  the  case  in  prolapsus  of 
the  bladder,  then  nitro-hydrochloric  acid,  of  the  strength  of  two 
minims  to  the  ounce  of  water,  should  be  used.  Whenever  pain  is 
caused  by  any  of  these  astringent  injections,  morphia  should  be  used 
afterward,  as  directed  by  Braxton  Hicks. 


ORGANIC    DISEASES   OF   THE   BLADDER.  ^1^95 

In  obstinate  cases  a  strong  solution  of  nitrate  of  silver  is  one  of 
the  most  reliable  remedies.  Twenty  grains  to  the  ounce  of  water 
has  been  used  with  great  benefit,  and  it  does  not  cause  as  much  pain 
as  might  be  supposed.  Very  small  quantities  only  can  be  used  at 
a  time — not  more  than  live  or  ten  drops.  The  only  trouble  which 
r  have  experienced  is  in  being  sure  of  injecting  that  small  quantity 
and  no  more.  My  favorite  method  of  making  such  applications  to 
the  interior  of  the  bladder  is  by  instillation,  as  it  is  called.  I  take  a 
glass  tube  of  the  size  and  shape  of  a  JN'o.  8  or  9  male  sound,  with  a 
small  rubber  bulb  attached  to  the  straight  end.  The  curved  point 
is  introduced  into  the  solution  to  be  used,  the  bulb  is  compressed  by 
the  thumb  and  finger,  and  then  relaxed,  which  draws  up  the  desired 
amount.  The  tube 
is  then  carried  into 
the  bladder,  and,  by 

Fig.  261. — Skene's  instillation  tube. 
again    compressing 

the  bulb,  the  fluid  is  easily  deposited  in  the  organ  (Fig.  261). 

If  a  larger  quantity  is  to  be  used,  it  can  be  introduced  through 
the  instrument  used  for  washing  out  the  bladder.  In  fact,  T  seldom 
use  the  pipette  now  except  for  medicating  the  urethra. 

There  is  one  rule  that  should  be  followed  in  using  nitrate  of  sil- 
ver in  the  treatment  of  cystitis,  which  is  this :  If  a  strong  solution 
is  used,  only  a  few  drops  should  be  employed,  and,  if  a  large  injec- 
tion is  made,  the  solution  should  be  mild.  I  am  indebted  to  Frof. 
John  W.  S.  Gouley  for  this  valuable  guide  in  the  use  of  this  remedy. 

Normal  urine  has  been  highly  recommended  as  an  injection  in 
cystitis.  The  urine  from  a  healthy  person  is  obtained  and  used  in 
the  same  way  as  the  other  injections  described.  I  have  always  looked 
upon  this  treatment  with  a  little  suspicion.  It  may  be  of  value  in 
cases  where  from  some  derangement  of  the  general  system  the  urine 
secreted  is  abnormal,  and  therefore  irritating  to  the  bladder,  and 
where  constitutional  treatment  can  not  remove  that  condition.  When 
the  urine  secreted  can  be  kept  in  a  normal  state,  it  must,  it  seems  to 
me,  be  as  acceptable  to  the  bladder  as  the  same  kind  of  urine  from 
another  person.  Theoretically,  one  would  expect  that  healthy  urine 
poured  into  the  bladder  from  the  kidneys  would  be  more  likely  to 
cure  cystitis  than  if  it  were  injected  through  the  urethra.  However, 
this  method  may  be  of  value  ;  but  one  thing  is  certain — it  fails  like 
all  other  injections  in  certain  cases. 

Iodoform  has  been  used  locally  in  cystitis,  and  with  good  effect ; 
but  I  regret  to  say  that  I  have  not  used  it  enough  to  test  its  merits 
fully. 


796  DISEASES  OF  WOMEN. 

One  great  obstacle  often  met  with  in  using  instillations  is  a  ten- 
der or  inflamed  urethra.  This  difhculty  I  have  recently  been  able 
to  overcome  by  using  cocaine.  It  is  applied  as  follows :  I  take  a 
pipette  like  the  one  described  above  but  larger,  till  it  with  cocaine 
solution,  and  introducing  the  tapering  part  of  it  into  the  meatus,  force 
the  solution  along  the  urethra  and  into  the  bladder.  This  often 
makes  the  rest  of  the  treatment  easy. 

Another  direct  method  of  treating  the  bladder  has  been  employed 
by  Dr.  Robert  Newman,  of  New  York,  who  has  made  some  useful 
contributions  to  the  therapeutics  of  vesical  disease.  He  employs 
the  endoscope  of  Desormeaux  to  make  the  diagnosis,  and  makes 
direct  applications  to  the  diseased  parts  through  that  instrument.  In 
ulceration,  he  has  been  very  successful  in  his  practice.  He  applies 
a  solution  of  the  nitrate  of  silver  (twenty  grains  to  the  drachm  of 
water)  to  the  ulcerated  surface,  and  by  carefully  regulating  the 
amount,  finds  that  the  pain  is  less  than  wlien  a  weaker  solution  is 
used  in  the  ordinary  way.  I  have  done  the  same  thing  ^vith  greater 
facility  by  using  the  endoscope  which  I  have  described.  The  in- 
strument is  introduced,  and  the  ulcerated  part  found ;  the  glass  tube 
is  drawn  out,  and  the  application  made  directly  to  the  diseased  part, 
through  the  rubber  speculum.  Forcible  and  extreme  dilatation  of 
the  urethra  has  been  advocated  in  the  treatment  of  cystitis  by  many 
surgeons  otherwise  well  informed.  Within  the  past  few  years  the 
medical  journals  have  contained  the  histories  of  many  cases  of  cys- 
titis said  to  have  been  cured  by  this  operation.  This  is  all  quite  er- 
roneous. Cystitis  can  no  more  be  cured  by  dilating  the  urethra 
tlian  could  a  gastritis  be  cured  by  dilating  the  sphincter  ani.  It  is 
a  fact  that  if  the  urethra  be  destroyed  by  overdistention,  inconti- 
nence will  follow,  and  the  perfect  drainage  of  the  bladder  may 
cure  the  inflammation  ;  but  verily  the  cure  is  worse  tlian  the 
disease.  I  am  sure  that  the  mistake  in  regard  to  the  value  of  this 
operation  in  cystitis  comes  from  its  having  been  practiced  in  cases  of 
acute  cystitis  which  would  have  ended  in  recovery  without  any  sur- 
gical treatment,  and  again  in  cases  of  inflammation  of  the  upper 
third  of  the  urethra  which  have  been  mistaken  for  cystitis.  On  the 
one  hand  the  operation  gets  the  credit  of  curing  a  disease  which 
cured  itself,  and  on  the  other  of  curing  a  disease  which  did  not  ex- 
ist. It  will  be  observed  that  in  the  cases  which  I  give  at  the  close 
of  this  section,  the  urethra  was  dilated  with  no  benefit,  and  to  these 
I  could  add  many  others  which  were  treated  in  the  same  way  with  a 
like  result. 

All  the  means  of  treatment  yet  described  will  fail  in  some  of  the 


ORGANIC   DISEASES   OF   THE    BLADDER.  797 

worst  cases  of  clironic  cystitis.  Indeed,  this  has  led  to  the  last  re- 
sort, as  I  look  upon  it,  namely,  cystotomy  for  the  establishment  of 
vesico-vaginal  tistula  to  drain  the  bladder  and  set  it  at  rest.  The 
perfect  rest  obtained  by  the  urine  flowing  out  through  the  fistula  as 
soon  as  it  enters  from  tlie  ureters  places  the  inflamed  surfaces  in  a 
condition  to  recover,  and  the  patient  is  relieved  from  the  constant 
pain  and  the  torments  of  urinating  every  few  minutes  night  and 
day. 

This  is  certainly  a  great  triumph,  and  is  especially  applicable  in 
cases  that  are  incurable  by  all  other  means.  Indeed,  it  is  adapted  to 
eases  which  are  incurable  by  this  operation,  because  it  gives  relief 
from  pain,  and  makes  the  last  days  of  an  incurable  sufferer  tolerable. 
Dr.  Willard  Parker,  I  believe,  was  the  first  to  do  cystotomy  for 
the  cure  of  cystitis  in  the  male,  and  Dr.  T.  A.  Emmet  adopted  the 
operation,  and  has  practiced  it  extensively  among  his  female  patients. 
In  fact,  he  has  become  a  zealous  advocate  of  this  method  of  treating 
cystitis.  In  his  book  on  gynecology,  in  speaking  of  cystitis  in 
women,  he  says  that  our  management  of  this  afliection  is  limited  to 
one  procedure,  and  that  is  vaginal  cystotomy. 

Such  a  dogmatical  statement  is  quite  in  opposition  to  facts  well 
known  to  many  in  the  profession.  Drainage  by  vesico-vaginal  fist- 
ula is  neither  the  surest,  safest,  nor  simplest  method  of  treating  cys- 
titis in  women,  but  only  one  method  to  be  employed  in  those  rare 
cases  which  do  not  yield  readily  to  other  means. 

While  writing  on  this  subject  some  years  ago,  I  obtained  from 
one  of  the  resident  surgeons  of  the  Woman's  Hospital  the  statement 
that  cystotomy  was  performed  for  the  relief  of  cystitis  on  seventeen 
cases  in  that  institution,  and  that  four  were  cured  and  thirteen  im- 
proved. This  shows  about  twenty-four  per  cent  of  recoveries,  and 
this  I  stated  in  my  book  on  "  Diseases  of  the  Bladder."  Dr.  Em- 
met in  his  book  on  gynecology  objects  to  this  statement  of  mine  as 
not  being  in  accordance  with  a  published  report  of  the  Woman's 
Hospital.  The  report  referred  to  was  not  published  at  the  time  that 
I  prepared  my  manuscript,  nor  did  I  see  it  until  after  my  book  was 
published.  I  presumed  that  the  interne  of  the  hospital  gave  me  a 
correct  report,  but  be  that  as  it  may,  Dr.  Emmet's  own  statistics  (as 
given  in  his  book,  page  788)  of  the  hospital  practice  are  less  favor- 
able to  cystotomy  for  the  cure  of  cystitis  than  those  quoted  by  me. 
They  show  but  about  twenty  per  cent  of  recoveries,  whereas  my 
statement  obtained  from  the  interne  was  twenty-four  per  cent.  This 
shows  that  if  I  made  a  mistake  it  was  in  favor  of  the  operation  ;  or 
else  if  I  was  correctly  informed  of  the  results  of  that  operation  at 


798  DISEASES  OF   WOMEN. 

that  time,  then  the  subsequent  hospital  experience  of  Dr.  Emmet 
has  been  more  unsatisfactory.  Dr.  Emmet's  method  of  making 
the  fistulous  opening  is  by  dividing  the  vesi co-vaginal  septum 
with  the  scissors,  and  then  introducing  a  glass  tube  to  keep  the 
opening  from  closing.  This  is  the  most  difficult  way  of  operating 
and  the  most  painful  to  the  patient  afterward.  The  wearing  of 
this  tube  has  been  a  torture  to  those  that  I  have  seen  using  it. 
There  are  two  other  methods  of  operating.  One  is  to  make  the 
opening,  and  then  stitch  the  mucous  membrane  of  the  bladder  to 
the  mucous  membrane  of  the  vagina,  thus  preventing  the  closing 
of  the  oi)ening,  and  at  the  same  time  enabling  the  edges  of  the 
wound  to  heal  in  a  short  time,  a  great  gain  in  itself.  The  other 
method  is  to  make  the  opening  with  the  galvano-  or  thermo-cau- 
tery.  Dr.  M.  A.  Fallen  was  the  first  to  operate  with  the  thermo- 
cautery. This  is  what  he  says  about  it :  "  The  main  difficulty 
hitherto  has  been  to  keep  the  incision  open  after  the  use  of  the 
scissors  or  knife.  Artificial  means  must  be  resorted  to,  such  as  an 
India-rubber  tube  passed  from  the  urethra  through  the  opening, 
which  is  annoying  and  painful ;  or  a  glass  button  introduced, 
which  is  difficult  to  retain,  and  when  retained  is  apt  to  beget  vesical 
tenesmus.  I  believe  that  the  use  of  the  actual  cautery  at  a  red 
heat  will  be  found  to  answer  all  purposes.  If  the  platinum  tip 
is  at  a  white  heat  it  cuts  through  too  rapidly,  and  we  are  apt  to  have 
as  much  h^Buiorrhage  as  with  the  knife  or  scissors.  Haemorrhage  is 
sometimes  quite  serious  after  incision  of  the  vesico-vaginal  septum, 
particularly  if  the  scissors  or  knife  strike  the  tortuous,  enlarged 
veins,  often  ramifying  upon  or  under  the  mucous  membrane  of 
the  bladder.  If  the  platinum  tip  of  the  cautery  be  heated  to  a 
white  heat,  it  cuts  through  as  rapidly  as  the  knife,  and  therefore  the 
haemorrhage  is  to  be  expected  ;  besides,  the  thin  pellicle  of  slough 
following  the  white-heat  tip  soon  peels  oli,  and  union  might  ensue. 
To  avoid  both  bleeding  and  contraction,  the  red-heat  tip  should  be 
slowly  passed  along  the  site  of  the  proposed  opening,  dividing  first 
the  mucous  membrane  of  the  vagina,  and  then  resting  for  a  moment 
or  so  to  allow  the  adjacent  vessels  to  contract  and  become  throm- 
botic. The  submucous  connective  tissue  is  then  burned,  and  after- 
ward the  bladder-wall  itself.  Extreme  delicacy  of  manipulation  is 
required  upon  the  part  of  the  surgeon,  lest  he  bum  directly  into 
the  cavity  of  the  bladder,  which  should  be  avoided  if  he  wants  to 
make  sure  of  a  result  that  will  prevent  haemorrhage,  contraction, 
and  subsequent  union. 

'•  The  care  after  an  operation  of  this  kind  consists  in  daily  cleans- 


ORGANIC   DISEASES    OF   THE   BLADDER. 


799 


ing  the  bladder  thoroiigldy  with  demulcent  warm  fluids,  such  as 
starch  or  flaxseed  water.  The  pain  in  the  bladder  following  the 
burning  is  comparatively  slight,  and  usnally  subsides  within  thirty-six 
or  forty-eight  hours." 

Dr.  John  Byrne,  of  Brooklyn,  operates  in  a  very  easy  and  satis- 
factory manner.  He  has  a  forceps,  one  blade  of  which  is  intro- 
duced into  the  bladder  and  the  other  into  the  vagina  to  grasp  the 
vesico-vaginal  septum.  The  blade  in  the  vagina  is  fenestrated  and 
the  blade  in  the  bladder  is  grooved.  The  theruio-cautery  knife  is 
introduced  through  the  fenestrum  of  the  forceps  and  the  septum  is 
divided,  the  knife  being  guided  by  the  forceps. 

This  method  makes  the  operation  simple  and  easy,  and  the  after 
treatment  is  also  greatly  simplified. 

One  serious  drawback  to  cystotomy  is  the  incontinence  which 
keeps  the  patient  in  such  an  uncomfortable  state  by  the  constant 
trickling  of  urine  from  the  fistula.  I  tried  to  obviate  this  trouble 
to  some  extent  by  using  a  hollow-globe  pessary,  made  of  hard  rub- 
ber, with  a  tube  attached  to  it.  The  globe  is  perforated  with  nu- 
merous small  holes  all  around,  except  for  about  half  an  inch  from 
where  the  tube  begms.  The  globe  is  introduced  into  the  vagina, 
and  the  tube  projects  through  the  introitus.  The  urine  collects  in 
the  globe,  and  escapes  through  the  tube ;  and  by  attaching  a  piece 
of  flexible  tubing  to  it  the  urine  can  be  conveyed  into  a  vessel. 
When  the  introitus  vulvae  is  small  and  the  sphincter  vaginae  perfect, 
this  answers  very  well,  especially  during  the  night,  when  the  patient 
is  in  the  horizontal  position.  When  worn  during  the  day,  it  is  ne- 
cessary to  have  a  rubber  bag  attached  to  the  leg  of  the  patient  to  act 
as  a  receptacle. 

Encouraged  by  my  success  with  the  globe-pessary,  I  had  another 
made,  shown  in  Fig,  262.  It  is  the  ordinary  Smith's  pessary,  with 
an  oblong  cup  on  the  upper 
anterior  portion  of  it,  which 
fits  over  the  fistula,  and  collects 
the  urine  and  guides  it  out  to 
a  urinal.  In  artificial  fistula, 
made  in  the  center  of  the  va- 
gina, this  pessary  answers  a 
most  valuable  purpose. 

I  was  led  to  devise  this 
way  of  relieving  patients  with 
vesico-vaginal  fistulae  by  hav- 
ing one  under  my  care  who  was  in  no  condition  to  be  operated  on 


Fig.  262. — Skene's  urinal  cup-pessary.  «,  rep- 
resents the  posterior  portion  which  sur- 
rounds the  cervix  uteri ;  b,  the  cup  ;  and  c, 
the  tube  which  conveys  the  urine  from  the 
cup  to  the  urinal. 


800  DISEASES  OF  WOMEN. 

for  the  cure  of  fistula,  owing  to  general  ill-health.  She  also  had 
severe  vulvitis,  and  the  urine  constantly  passing  over  the  inflamed 
surface  drove  her  almost  insane.  Her  suffering  was  terrible  ;  so  to 
relieve  her  until  I  could  operate  I  had  made  the  perforated  stem 
globe-pessary,  or  whatever  one  may  see  fit  to  call  it. 

I  come  now  to  what  I  believe  to  be  another  important  part  of 
the  treatment  of  these  obstinate  cases.  I  allude  to  drainage  by 
means  of  the  self-retaining  catheter.  Years  ago  I  had  a  very  trou- 
blesome case  of  cystitis,  which  I  faithfully  tried  to  relieve  by  all  the 
means  at  my  command,  but  without  success.  My  patient  was 
obliged  to  urinate  every  fifteen  or  twenty  minutes,  day  and  night, 
and  the  pain  and  want  of  rest  were  fast  wearing  her  out.  In  the 
hope  of  securing  rest  at  night  I  introduced  a  Sims's  self-retaining 
catheter  with  a  rubber  tube  attached,  to  convey  the  water  to  the 
urinal.  The  result  was  very  gratifying.  She  could  sleep  well,  and 
gained  in  health  and  strength  rapidly,  and  the  cystitis  gradually 
improved.  Since  that  time  I  have  resorted  to  drainage  by  catheter 
in  cases  which  resisted  the  ordinary  treatment. 

A  description  of  this  plan  of  treatment  will  be  found  in  the 
"  Proceedings  of  the  New  York  Obstetrical  Society,"  recorded  in 
the  "  American  Journal  of  Obstetrics,"  for  Febraary,  1874.  This 
method  has  been  successfully  practiced  by  Hunter  McGuire,  a  com- 
plete history  of  his  case  being  published  in  the  "  Richmond  and 
Louisville  Medical  Journal"  for  June,  1874.  Dr.  McGuire  took  a 
piece  of  tubing  about  twelve  inches  long,  and  made  holes  in  about 
four  inches  of  the  end  of  it  with  a  shoemaker's  punch.  He  passed 
a  silver  tube  into  the  bladder,  and  then  pushed  the  gum  tube  through 
it  until  the  perforated  four  inches  were  coiled  in  the  bladder.  This 
was  retained  in  place  by  tapes  fixed  to  the  tube  and  to  a  bandage 
passed  around  the  patient's  body.  The  tube  became  obstructed  by 
mucus,  but  was  easily  cleared  by  injecting  warm  water  through  it. 
But  this  long  piece  of  tubing  being  frequently  expelled  by  the  blad- 
der, the  doctor  tried  a  shorter  piece,  and  found  it  was  more  readily 
retained.  The  patient  after  a  time  went  about  and  attended  to  her 
household  duties  while  wearing  the  tube,  and  in  about  four  months 
made  a  perfect  recovery. 

This  method  of  drainage  is  an  improvement  on  Sims's  catheter, 
but  still  is  not  all  that  w^e  require.  Since  my  first  case  I  have  found 
that  a  good  self-retaining  catheter  for  this  purpose  is  Holt's,  made 
of  perfectly  flexible  rubber,  and,  in  place  of  an  eye  in  the  point,  is 
cut  into  strips  near  the  end,  and  made  to  spread  out  like  an  umbrella 
(Fig.  203). 


OEGANIC   DISEASES   OF   THE   BLADDER. 


801 


Another  instrument  for  drainage  is  a  catheter  devised  by  Prof. 
Goodman,  and  described  in  the  "  Richmond  and  Louisville  Medical 
Journal,"  for  February, 
1S69,  as  being  used  in  the 
treatment  of  vesico- vaginal 
fistula,  and  I  have  recently 
learned  that  he  has  used  it 
for  years  in  treating  cystitis. 
The  following  is  Dr.  Good- 
man's description  of  his  cath- 
eter :  "  It  is  about  two  inches 
in  length,  and  bent  to  cor- 
respond to  the  curvature  of 

the  urethra  ;   at  the  lower  or      ^i«-  263.— Holt's  catheter,  with  its  modification. 

external  end  there  is  a  button  ten  sixteenths  of  an  inch  in  diameter, 
and  at  the  other,  or  external,  end  a  shouldered,  cup-shaped  expan- 
sion, varying  from  five  sixteenths  to  seven  sixteenths  of  an  inch  in 
diameter,  and  beveled  on  the  convex  aspect  of  the  instrument,  in 
order  to  make  it  easier  of  introduction,  and  perforated  with  a  num- 
ber of  small  holes.  The  stem,  intervening  between  these  two  por- 
tions, is  one  and  one  half  inch  in  length,  a  quarter  of  an  inch  in 
diameter,  with  as  large  a  bore  as  is  compatible  with  the  requisite 
strength.  This  catheter  is  self -retaining  in  all  positions  of  the  pa- 
tient ;  first,  by  reason  of  the  bulb  at  its  upper  extremity,  which 
passes  beyond  the  urethra  into  the  bladder ;  second,  on  account  of 
its  curved  shape  ;  and  third,  in  consequence  of  the  button  being 
overlapped  and  grasped,  as  it  were,  by  the  vulva.  At  the  lower  end 
there  is  a  slight  projection,  or  knob,  over  which  an  India-rubber  tube 
may  be  slipped,  this  being  inserted  into  a  bottle  at  night,  or  into  a 
urinal  when  the  patient  is  up ;  her  person  may  thus  be  kept  per- 
fectly clean."  I  like  this  instrument  for  the  purpose  of  draining  the 
bladder,  when  the  patient  can  tolerate  it;  but  I  believe  that  the 
sharp  point  of  the  conical  end  which  rests  in  the  bladder  is  objec- 
tionable, and  I  can  see  no  good  reason 
for  having  it  so.  I  had  the  point 
made  larger  and  rounder  (Fig.  248), 
and  found  that  it  answered  certainly 
as  well,  and  was  easier  to  introduce. 
In  drainage  by  any  method  it  must 
be  remembered  that  the  instrument  should  be  frequently  removed 
and  cleaned,  and  the  bladder  occasionally  be  washed  out  at  the  same 

time. 

52 


Fig.    264. — Skene's   modification   of 
Goodman's  self-retaininp;  catheter. 


802  DISEASES  OF  WOMEN". 

Fortunate  it  is  that  we  have  this  method  of  treatment  now  at  our 
command.  By  this  means  we  can  restore  to  health  and  comfort 
many  of  those  cases  which  have  hitherto  been  considered  hopeless. 

I  believe  that  a  normal  condition  of  the  urethra  is  a  prerequisite 
to  drainage.  When  there  is  tenderness  of  the  urethra,  the  patient 
can  not  tolerate  the  catheter ;  this  form  of  treatment  would  be  more 
popular  if  this  point  had  not  been  overlooked. 

Where  there  is  hsemoiThage  into  the  bladder,  the  rules  already 
given  are  to  be  followed. 

In  cases  of  exfoliation  of  the  whole  or  a  part  of  the  mucous  mem- 
brane of  the  bladder,  and  the  organ  is  evidently  trying  to  expel  its 
contents,  the  urethra  should  be  sufficiently  dilated  to  allow  the  mass 
to  pass,  or  it  may  be  removed  by  the  forceps,  if  this  can  be  done 
without  force.  After  its  extraction  antiseptic  and  disinfectant  meas- 
ures should  be  resorted  to.  Injections  of  lime-water,  weak  solutions 
of  carbolic  acid  or  salicylic  acid  should  be  used,  and  the  organ 
washed  out  once  or  twice  daily  with  warm  water.  Above  all,  urine 
should  not  be  permitted  to  remain  in  the  tender  organ  for  any  length 
of  time. 

In  passing  the  catheter,  especially  in  cases  where  the  bladder  is 
bound  to  neighboring  organs,  care  should  be  taken  to  let  no  air  enter, 
for  Winckel  has  seen  vesical  catarrh  follow  its  introduction,  and 
makes  it  a  point,  even  after  using  Rutenberg's  apparatus,  to  wash 
out  the  organ  with  some  antiseptic. 

Prognosis. — In  acute  cystitis  occurring  in  a  healthy  subject  the 
outlook  is  good,  recovery  being  usually  attained  in  from  one  to  three 
weeks.  When  occurring  in  the  course  of  pregnancy,  or  after  de- 
livery, the  prognosis  is  not  so  good,  there  being  a  tendency  for  the 
disease  to  become  chronic,  and,  even  if  cured,  it  leaves  a  weak  state 
of  the  organ  afterward.  The  prognosis  in  diphtheritic  and  croupous 
cystitis  depends  mainly  on  the  systemic  disorder,  and  is,  therefore, 
grave. 

When  due  to  displacements  of  the  gravid  uterus,  the  prognosis 
will,  of  course,  depend  on  the  ability  to  replace  the  womb.  In  can- 
cer of  the  womb,  vagina,  anterior  vaginal  wall,  or  of  the  bladder  it- 
self, the  prognosis  is  the  same  as  in  malignant  disease  generally.  In 
chronic  cystitis,  with  ulceration,  the  prognosis  is  very  serious ;  for, 
with  the  tendency  to  haemorrhage,  extension  to  the  peritonaeum, 
perforation,  blood-poisoning,  with  low  systemic  condition,  extension 
to  the  renal  pelves,  and  destruction  of  one  or  both  kidneys,  a  fatal 
termination  comes  sooner  or  later,  and  may  come  when  we  least 
expect  it. 


ORGANIC   DISEASES   OF   THE   BLADDER.  803 

About  one  half  of  tlie  cases  of  exfoliation  of  the  vesical  mucous 
membrane  have  recovered.  Gangrenous  inflammation,  involving,  as 
it  usually  does,  all  the  coats  of  the  bladder,  is  the  most  speedily  and 
certainly  fatal  of  all  the  forms  of  cystitis. 

Hygiene. — There  are  certain  points  to  be  considered  in  the  man- 
agement of  all  cases  where,  from  certain  circumstances,  vesical  dis- 
ease is  to  be  expected,  and  also  M^here  it  already  exists. 

In  pregnant  women,  where  the  pelvic  organs  are  constantly  tend- 
ing to  congestion,  attention  should  be  given  to  the  patient's  circula- 
tion ;  friction  to  the  legs,  feet,  and  arms ;  daily  warm  baths ;  mod- 
erate exercise,  alternated  with  periods  of  rest  in  the  recumbent 
position,  and  astringent  or  saline  vaginal  injections  should  be  em- 
ployed. Upon  the  least  suspicion  of  malposition  of  the  uterus,  that 
organ  should  be  examined,  and,  if  malposed,  replaced.  The  diet 
should  be  bland  and  unirritating,  yet  nourishing,  and  any  indigestion 
corrected  as  speedily  as  possible.  An  occasional  saline  laxative  will 
prove  of  use  when  there  is  constipation.  Tonics  will  be  found  serv- 
iceable in  some  instances. 

In  women  not  pregnant,  where  there  is  a  tendency  to  vesical  dis- 
ease, the  same  plan  should  be  followed,  with  the  addition  of  injec- 
tions of  water,  as  hot  as  can  be  borne,  into  the  vagina  every  night, 
as  recommended  by  Dr.  Emmet.  ]^ot  less  than  a  gallon  should  be 
used.  Where  from  any  cause  retention  exists,  or  there  is  a  tendency 
thereto,  the  urine  should  be  drawn  carefully  with  a  soft  catheter, 
well  soaped,  being  sure  that  the  catheter  imperfectly  clean,  and  that 
no  air  is  permitted  to  enter  the  viscus  for  the  reasons  already  given. 
Winckel  believes  that  in  every  institution  for  lying-in  women  each 
patient  should  either  have  a  new  catheter  assigned  to  her,  or  one 
rendered  absolutely  clean  b}^  some  efficient  chemical  process.  To 
the  enforcement  of  this  rule  Winckel  attributes  the  great  exemption 
from  vesical  inflammation  enjoyed  by  the  patients  in  the  Dresden 
House  for  Child-bearing  Women. 

I  must  fully  indorse  the  teaching  of  this  great  authority.  I  have 
seen  so  much  bladder  trouble  brought  on  by  the  careless  use  of  foul 
catheters  that  I  have  come  to  look  upon  clumsy  operators  and  un- 
clean instruments  as  the  most  common  causes  of  cystitis. 

In  weakness  of  the  detrusor  vesicge  (which  is  not  an  uncommon 
affection  in  pregnant  women),  Winckel  has  achieved  great  success 
with  injections  of  simple  warm  or  medicated  water  into  the  bladder. 

In  irritable  bladder,  -with  a  tendency  to  congestion,  a  solution  of 
borax  may  be  injected  with  good  results. 

Every  woman,  even  at  the  risk  of  disturbing  company  or  neglect- 


804 


DISEASES   OF   WOMEN. 


ing  important  duties,  should  evacuate  the  bladder  regularly,  and 
never  long  resist  the  desire  to  urinate. 


ILLUSTRATIVE    CASES. 


Chronic  Cystitis  with  Intermittent  Drainage  ;  Death  from  Perfora- 
tion of  the  Bladder. — The  patient  was  under  mj  care  from  November 
9,  1869,  to  February  10,  1870,  while  suffering  from  a  cystitis,  which 
began  after  one  of  her  confinements  several  years  before.  At  that 
time  she  had  a  well-marked  cystitis  of  the  pui-ulent  variety.  She 
was  treated  by  injections — the  method  in  vogue  at  that  time — with 
some  benefit.  I  also  employed  drainage  part  of  the  time  by  intro- 
ducing a  catheter  in  the  evening,  and  letting  it  remain  all  night. 
This  gave  her  great  relief,  and  permitted  her  to  sleep — a  blessing 
which  she  had  not  enjoyed  for  several  years.  She  was  improving 
in  her  general  health,  although  her  local  disease  remained  about  the 
same,  or  at  least  only  a  little  improved.  She  expected  to  return  for 
further  treatment,  but,  her  husband  becoming  paralyzed,  she  was 
obliged  to  give  up  the  care  of  herself  to  look  after  her  family.  From 
that  time  up  to  July,  1882,  she  continued  to  suffer  tortures  during 
the  day,  while  she  was  obliged  to  be  up  and  around  attending  to  her 
liousehold  duties.  At  night  she  obtained  relief  by  wearing  the  cath- 
eter, which  she  had  continued  to  use  ever  since  she  was  taught  to  do 
so,  twelve  years  Ijefore.  Her  sufferings  were  almost  beyond  descrip- 
tion, but,  having  an  iron  constitution  and  extraordinary  will-power, 
she  managed  to  Hve  until  the  summer  of  1882.  During  June  and 
July  of  that  year  she  failed  more  rapidly.  Having  heard  of  dilata- 
tion of  the  urethra  as  a  cure  for  cystitis,  she  urged  her  physician  to 
try  that  operation.  He  did  so,  and  repeated  the  operation  one  week 
later.  The  only  effect  of  this  treatment  (as  stated  in  the  notes  of 
her  history,  which  I  obtained;  was  to  reduce  the  number  of  evacua- 
tions from  one  hundred  and  sixty  to  one  hundred  in  twenty-four 
hours.  Her  physician  then  injected  her  bladder  in  the  hope  of  re- 
lieving the  inflammation  and  also  overcoming  the  contraction,  which 
was  very  marked.  Immediately  after  the  first  and  only  injection  she 
was  seized  with  violent  abdominal  pains,  and  rapidly  developed  a 
peritonitis,  which  proved  fatal  on  the  second  day. 

On  post-mortem  it  was  found  that  the  bladder  was  adherent  to 
all  the  viscera  around  it,  the  result,  no  doubt,  of  a  former  pericys- 
titis. Upon  the  posterior  wall  of  the  bladder,  and  directly  opposite 
the  urethra,  there  was  a  nipple-like  projection  outward,  with  an 
opening  at  its  apex  large  enough  to  admit  a  lead-pencil.  This  pro- 
tuberance had  been  produced  by  the  long  use  of  the  hard  catheter. 


ORGANIC   DISEASES    OF   THE   BLADDER.  S05 

The  instniment  had  worn  through  the  inner  walls  of  the  bladder 
until  the  pai-ts  had  become  less  resistant ;  it  then  pushed  the  remain- 
ing muscular  tissue  and  peritonaeum  outward,  and  formed  the  nipple- 
like  projection.  At  the  time  of  the  fatal  attack,  the  catheter  had 
made  its  way  through  all  the  coats  of  the  bladder  except  the  thick- 
ened peritonaeum.  The  rupture  of  the  peritonaeum  was  caused  bv 
the  injection.  That  was  the  belief  of  the  physician  in  attendance, 
and  the  history  points  detinitely  to  the  same  conclusion.  The  blad- 
der was  firmly  contracted  and  in  distensible ;  its  retaining  capacity 
did  not  exceed  half  an  ounce.  The  muscular  wall  was  oyer  haK 
an  inch  thick ;  the  mucous  membrane  was  entirely  destroyed  by  the 
inflamtuation. 

Pumlent  Cystitis;  Recovery  after  Two  Years'  Treatment. — This 
patient  was  a  lady  possessing  a  remarkably  good  organization.  She 
was  married,  and  had  one  child.  Her  age  was  thirty  when  her  illness 
began.  TVliile  riding  horseback  she  was  thrown  off,  and  sustained 
some  apparently  slight  injuries.  Her  health  up  to  this  time  had  been 
yery  good,  but  from  the  time  of  her  accident — September,  ISTS — she 
had  symptoms  of  cystitis.  She  was  residing  in  the  far  ^est  at  the 
time  of  the  accident,  and,  as  1  did  not  see  her  for  seyeral  years  after, 
and  haye  not  been  able  to  correspond  with  the  surgeon  who  then  at- 
tended her,  I  do  not  know  the  relation  which  the  injury  sustained  at 
that  time  bears  to  the  deyelopment  of  the  cystitis.  I  only  know  that 
the  one  followed  the  other  immediately.  The  cystitis  persisted,  and 
the  constitutional  symptoms  increased  from  time  to  time.  She  then 
returned  from  the  West  to  Xew  England  to  be  under  the  care  of  her 
father,  who  is  a  physician  of  known  ability  and  large  experience. 
He  gaye  her  eyery  attention,  and  placed  her  in  the  care  of  a  neigh- 
boring physician,  who  has  a  high  reputation  as  a  gynecologist.  "With- 
out  o-iyino;  full  details  of  her  treatment  at  that  time.  I  may  fairly 
state,  upon  information  receiyed  from  her  father  and  her  physician, 
that  all  the  recognized  means  of  treatment  were  tried,  including 
complete  dilatation  of  the  urethra  on  two  occasions.  The  cystitis 
was  not  at  allrelieyed  by  the  treatment,  and  the  constitutional  symp- 
toms increased  continuously,  until  she  became  confined  to  bed.  Hay- 
ing a  highly  sensitive  neryous  system,  she  suffered  greatly  from  wane 
of  sleep  and  the  constant  pain  of  cystic  tenesmus.  I  first  saw  her 
in  consultation  about  a  year  fi'ora  the  time  when  she  was  first  taken 
ill.  It  was  then  that  this  much  of  her  history  was  obtained.  She 
continued  under  treatment  for  six  months  longer,  and,  at  the  end  of 
that  time,  she  consulted  one  of  the  best  known  and  most  worthy 
authorities  in  ^S^ew  York.     He  adyised  cystotomy  and  drainage  for 


806  DISEASES  OF  WOMEN. 

six  months  or  longer,  stating  at  the  same  time  that,  in  view  of  the 
failure  of  her  former  treatment  to  give  relief,  there  was  nothing  else 
left  to  be  done.  She  decUned  to  submit  to  the  operation  at  that 
time.  Her  father  sent  her  to  me  about  two  and  a  half  years  later. 
At  that  time  she  was  obliged  to  urinate  about  every  hour,  night 
and  day.  She  suffered  from  constant  tenesmus,  and  her  nervous 
system  was  greatly  debilitated.  Dr.  McCorkle  examined  the  urine 
for  me,  and  found  that  it  contained  a  large  quantity  of  pus,  and 
that  there  was  a  remarkable  absence  of  epithelial  cells.  The  doctor's 
report  was  that  the  specimen  was  pus,  containing  a  small  quantity 
of  urine,  and  evidently  came  from  a  bladder  which  had  entirely  lost 
the  upper  layer  of  its  mucous  membrane.  The  diagnosis  then  made 
was  chronic  purulent  cystitis.  It  appeared  to  me  that  the  case  was 
one  which  called  for  cystotomy ;  but,  knowing  the  objection  of  the 
patient  to  that  operation,  treatment  was  undertaken,  and  the  results 
soon  gave  some  slight  encouragement.  The  constitutional  treatment 
was  at  first  chiefly  tonic  in  character,  and  subsequently  she  took  saline 
waters,  lithia  waters,  bromide  of  lithia,  and,  Anally,  buchu,  benzoin, 
tar,  turpentine,  and  the  like.  These  last  preparations,  however,  did 
not  help  her,  and  were  not  long  continued.  The  local  treatment 
was  at  first  instillations  of  a  warm  solution  of  borax.  Half  an  ounce 
was  instilled  at  a  time,  and  repeated  until  from  eight  to  twelve 
ounces  were  used  at  each  treatment.  The  instillations  were  always 
made  wdth  very  low  pressure.  As  the  sensitiveness  of  the  parts 
diminished,  the  quantity  used  was  increased  up  to  one  ounce,  but 
never  beyond  that.  Three  months  of  this  treatment  showed  im- 
provement. There  was  less  pain,  and  the  patient's  general  health 
had  improved  considerably.  About  this  time  nitrate  of  silver  was 
used,  and,  later,  sulphate  of  zinc  in  solution  of  various  degrees  of 
strength,  but  this  always  caused  pain.  Indeed,  the  suffering  caused 
by  this  kind  of  treatment  was  great,  and  the  benefit  which  followed 
being  very  little,  it  was  given  up.  I  then  began  to  use  instillations 
of  an  infusion  of  hydrastis  Canadensis,  containing  a  small  quantity 
of  salicylate  of  soda,  which  was  used  to  prevent  decomposition  of 
the  infusion.  I  am  now  satisfied  that  the  salicylate  was  of  value  in 
its  effect  ujion  the  suppurating  mucous  membrane.  The  hydrastis 
wasvery  faithfully  used,  first  by  myself,  and  subsequently  by  the 
patient,  who  made  the  instillations  with  unusual  intelligence  and 
care.  The  result  was  a  gradual  diminution  of  the  pain  and  lessening 
of  the  frequency  of  urination.  The  pus  diminished  in  quantity,  and 
simultaneously  young  epithelial  cells  appeared  in  the  urine,  and  in- 
creased in  number  as  the  pus  diminished.     At  the  end  of  one  year 


ORGANIC   DISEASES   OF   THE   BLADDER.  807 

of  treatment  the  local  and  constitutional  symptoms  liad  all  disap- 
peared. The  urine  was  normal,  and  the  patient  had  fully  recovered, 
excepting  that  she  was  obliged  to  urinate  about  every  four  hours. 
This  was  owing  to  contraction  of  the  bladder.  To  overcome  this, 
gradual  distention  was  practiced.  The  patient  was  directed  to  re- 
tain her  urine  until  discomfort,  not  pain,  was  felt.  Injections  were 
used,  each  time  distending  the  bladder  a  trifle  more,  always  stopping 
short  of  causing  pain.  About  two  years  from  the  time  she  first 
came  under  my  care  she  was  perfectly  cured  of  the  cystitis,  and  had 
regained  her  normal  retaining  power.  Four  more  years  have  passed, 
and  there  is  not  the  slightest  evidence  of  any  return  of  the  former 
affection. 

Cystitis  treated  by  Cystotomy  without  Benefit. — This  lady,  thirty- 
four  years  of  age,  is  married,  and  had  four  children.  She  is  said  to 
have  had  retroversion  of  the  uterus,  which  was  held  in  its  abnormal 
position  by  adhesions.  She  was  treated  for  this  displacement  in  the 
Woman's  Hospital  of  New  York,  so  she  said,  and,  while  under  treat- 
ment, a  cystitis  was  developed,  which  continued  until  I  saw  her. 
After  leaving  the  hospital,  she  became  pregnant,  and  her  sufferings 
increased.  Two  years  ago,  when  her  last  child  was  four  weeks  old, 
she  consulted  a  physician  here  in  Brooklyn,  who  advised  cystotomy, 
and  soon  after  he  performed  the  operation,  using  the  cautery.  She 
experienced  some  relief  from  the  operation,  but  she  still  suffered 
very  acutely.  Being  led  to  hope  that  in  time  the  operation  would 
cure  her,  she  bore  her  afflictions  for  nearly  a  year,  when  she  con- 
sulted me  on  the  5th  of  September,  1881.  I  then  found  her  to  have 
the  tubercular  diathesis,  rather  well  marked,  but  there  was  no  appar- 
ent disease  of  the  lungs  at  that  time.  The  vesico- vaginal  fistula 
made  by  the  operation  was  large  enough  to  admit  the  little  finger, 
and  the  drainage  of  the  bladder  was  quite  complete.  Yet,  strange 
to  say,  she  had  constant  pain  in  the  bladder,  and  a  desire  to  urinate. 
These  symptoms  I  found  to  be  due  to  inflammation  and  ulceration 
of  the  urethra  and  bladder  below  the  fistula.  The  disease  at  this 
location  caused  pain  and  irritation,  which  provoked  reflex  action, 
such  as  that  which  arises  from  the  presence  of  urine  in  the  bladder, 
but  in  a  much  greater  degree.  General  tonic  treatment  was  advised, 
and  local  treatment  employed  to  relieve  the  inflammation  of  the 
urethra  and  neck  of  the  bladder.  Locally^  she  improved  slowly. 
The  pain  and  vesical  tenesmus  subsided  almost  wholly,  but  she  has 
not  yet  recovered  completely.  My  object  was  to  cure  the  local  dis- 
ease, and  then  close  the  fistula.  This  I  shall  never  be  able  to  do. 
While  the  local  disease  is  improving,  she  is  developing  phthisis  pul- 


808  DISEASES  OF  WOMEN. 

monalis,  which  prechides  all  thought  of  operating  to  close  the  fistula. 
The  facts  in  this  history,  which  I  trust  will  be  borne  in  mind,  are, 
that  this  patient  was  of  a  tubercular  organization ;  that  cystotomy 
did  not  cure  her  cystitis  and  urethritis,  nor  relieve  her  suffering  to 
any  marked  extent. 

Cystotomy  for  the  Cure  of  Cystitis  without  Benefit;  Death  from 
Phthisis  following  Pneumonia  contracted  while  under  Treatment. — Six 
years  ago  I  had  a  case  of  cystitis  under  observation,  which  illustrates 
the  same  facts  in  pathology  and  therapeutics  as  in  the  case  just  re- 
lated. 

I  shall  give  a  very  brief  outline  of  the  history  simply  to  show  the 
result  obtained  by  another  method  of  doing  the  same  operation. 
This  patient  was  a  married  woman,  who  had  several  children.  She 
was  of  a  highly  nerv^ous  temperament,  and  came  from  a  tubercular 
family.  She  consulted  me  for  cystitis,  the  cause  of  which  is  not 
recorded  in  her  history.  I  treated  her  with  injections  for  several 
months  without  benefit.  I  also  dilated  her  urethra,  with  the  same 
result.  In  fact,  I  believe  she  rather  grew  worse,  in  place  of  better, 
while  under  my  care.  Her  general  health  failed  noticeably  at  any 
rate,  and  she  gave  signs  of  a  tubercular  deposit  going  on  in  her 
lungs.  Her  friends  urged  her  to  enter  the  Woman's  Hospital  in 
New  York.  She  did  so,  and  was  under  the  care  of  Dr.  Emmet, 
who  performed  cystotomy,  which  he  did  by  incision  and  keeping 
the  fistula  open,  first  by  his  glass  tube,  and  afterward  by  dilatation 
with  the  finger.  After  the  operation,  she  had  an  attack  of  ])neu- 
monia — at  least,  she  told  me  this  when  she  returned  from  hospital. 
Upon  her  return  home,  I  found  that  she  had  been  much  relieved  of 
her  most  urgent  symptoms  by  the  operation.  Still,  there  was  cys- 
titis remaining,  and  she  had  vesical  pain  and  tenesmus.  The  tuber- 
cular disease  of  the  lungs  had  progressed  rapidly,  and  that  portion 
of  her  lung  which  was  involved  in  the  pneumonia  never  cleared 
up.  Her  strength  rapidly  failed,  and  she  died  before  the  cystitis 
subsided. 

CROUPOUS  AND   DIPHTHERITIC   CYSTITIS. 

Croupous  and  diphtheritic  diseases  of  the  bladder  are  very  rare, 
and  therefore  require  but  a  brief  notice  here.  From  the  difficulties 
that  have  existed  in  the  detection  of  the  exact  pathological  conditions 
in  diseases  of  the  bladder,  we  may  presume  that  mild  attacks  of  these 
affections  have  been  overlooked  or  not  correctly  diagnosticated.  But, 
even  granting  this,  we  are  compelled,  from  the  few  recorded  cases, 
to  believe  that  croup  and  diphtheria  of  the  bladder  seldom  occur. 


ORGANIC  DISEASES   OF  THE   BLADDER.  809 

What  little  exact  knowledge  we  possess  on  this  subject  has  been 
obtained  to  a  great  extent  from  post-mortem  examinations,  and 
from  this  statement  it  will  be  inferred  and  correctly  too,  that  these 
diseases,  especially  diphtheria,  tend  to  end  fatally. 

From  the  names  employed  one  would  naturally  suppose  that 
these  affections  were  exactly  the  same  as  the  diseases  of  the  mucous 
membrane  of  the  air-passages,  known  as  croup  and  diphtheria.  Be 
that  as  it  may,  it  will  suffice  for  my  present  purpose  to  have  it  un- 
derstood that  in  these  diseases  of  the  bladder  there  is  developed  an 
exudation  or  membrane  like  of  that  of  croup  or  diphtheria. 

The  pathology  of  the  local  lesion  in  these  two  diseases  differs 
only  in  the  depth  of  tissue  involved  and  in  the  character  of  the 
membranous  formation.  Thus  in  croupous  cystitis,  the  false  mem- 
brane, while  moderately  adherent,  is  usually  on  the  surface,  covers 
the  whole  or  most  of  the  mucous  membrane  of  the  bladder,  and 
sometimes  portions  of  the  outer  genitals,  and  is  fibro-epithelial  in 
structure. 

The  diphtheritic  membrane,  on  the  contrary,  dips  deeply  into 
the  mucous  membrane  of  the  bladder,  exists  usually  in  scattered 
patches,  and  is  denser  and  more  fibrous  in  character,  its  interstices 
being  filled  with  little  rounded  cells  and  some  fatty  and  granular 
matter. 

Exfoliation  of  the  affected  portions  of  the  vesical  mucous  mem- 
brane usually  results  from  this  diphtheritic  inflammation,  as  in  the 
analogous  affection  in  the  throat.  When  the  membrane  comes 
away,  ulcers  of  varying  size  and  depth  are  left  to  mark  its  former 
site.  The  destructive  processes  are  not  alone  confined  to  the  mu- 
cous and  submucous  tissues,  but  in  some  cases  involve  the  muscular 
coat  of  the  organ.  The  whole  vesical  surface,  not  covered  with  the 
membranous  exudate,  is  of  a  deep-red  color,  and  in  some  places 
ecchymotic,  especially  about  the  exudation.  The  inflammation  is 
truly  acute,  and  passes  rapidly  from  the  stage  of  mucous  exudation 
to  that  of  epithelial  exfoliation  and  pus  formation. 

Symjytomatology. — The  symptoms  in  no  way  differ  from  those  of 
acute  cystitis,  save  that  as  a  rule  they  are  more  intense  and  the  con- 
stitutional symptoms  are  more  severe.  The  nervous  system  is  usu- 
ally profoundly  affected.  There  is  pain  before,  during,  and  after 
micturition — pain  that  may  be  purely  local,  felt  in  the  outer  genitals, 
or  radiate  in  all  directions. 

When  the  shreds  of  broken-down  membrane  separate,  they  may 
block  up  the  urethra,  and  cause  retention  and  decomposition  of 
urine,     Eetention,  however,  may  be  produced  at  any  time  by  in- 


810  DISEASES   OF  WOMEN. 

tense  inflammatory  tumefaction  of  tlie  urethra,  which  is  often  in- 
volved. 

This  exfoUation  of  false  membrane  must  not  be  confounded 
with  the  slouffhinor  of  the  mucous  membrane  of  the  bladder  caused 
by  pressure  from  overdistention  or  very  severe  inflammation. 

As  the  symptomatology  of  these  diseases  is  very  much  the  same 
as  those  of  acute  and  chronic  cystitis,  it  may  be  best  not  to  enlarge 
upon  them  here,  as  that  would  involve  much  useless  repetition. 

Diagnosis. — Microscopical  examination  of  the  urine,  but  more 
especially  of  the  tissue  shreds,  will  afford  much  reliable  information. 
Wheu  a  membrane  is  found  consisting  of  flbrillge  interspersed  with 
numerous  small  nucleated  cells,  having  undergone  fatty  degenera- 
tion, and  involving  the  superficial  mucous  or  muscular  layer,  the  case 
may  be  set  down  as  one  of  diphtheritic  cystitis.  The  urine  rarely 
affords  any  positive  information  ;  and  really  it  is  useless  to  attempt 
to  make  a  differential  diagnosis  between  these  diseases  and  ordinary 
cystitis  in  which  there  is  much  destruction  of  tissue. 

Thus  far  I  have  had  no  opportunity  of  examining  croupous  or 
diphtheritic  disease  of  the  bladder  with  the  endoscope,  and  can  not 
say  how  much  information  could  be  obtained  in  this  way.  \  pre- 
sume that  much  could  be  gained  by  this  instrument,  and  I  base  this 
opinion  upon  the  examination  of  several  cases  of  catarrhal  and 
croupous  inflammation  of  the  rectum.  In  these  cases  the  distinction 
between  catarrh  and  croup  could  be  easily  and  positively  made  by 
the  endoscopic  appearances,  and  I  believe  that  what  has  been  done 
in  determining  rectal  disease  could  be  accomplished  in  diseases  of 
the  bladder. 

In  these  cases  the  vesical  walls  are  very  fragile,  and  this  should 
be  borne  in  mind  in  using  either  catheter  or  endoscope.  This  con- 
dition would  preclude  the  distention  of  the  bladder  with  air  and 
examination  with  Ttutenberg's  apparatus. 

Prognosis. — This  is  very  grave  indeed. 

Treatment. — This,  in  brief,  is  to  keep  the  patient  perfectly  quiet, 
to  let  the  diet  be  the  most  sustaining,  the  drinks  free  and  bland,  and 
to  keep  the  bladder  pretty  well  emptied,  to  allay  the  pain  and  spasm 
by  the  judicious  exhibition  of  narcotics,  preferably  by  the  vagina,  in 
suppository.  The  bladder  should  be  washed  out  daily  with  warm 
water,  containing  a  little  of  Labarraque's  solution  or  a  little  carbolic 
acid.  jV[uch  relief  of  both  pain  and  spasm  will  thus  be  afforded,  even 
when  the  inflammation  is  at  its  highest. 

Tissue  shreds  should  be  removed  as  soon  as  their  presence  is  as- 
certained. 


ORGANIC  DISEASES   OF   THE   BLADDER.  811 


CYSTITIS   WITH   EPIDERMOID   CONCRETIONS. 

This  is  a  very  rare  affection  of  the  bladder,  and  I  only  mention 
it  as  a  pathological  curiosity.  Rokitansky  supposes  it  to  be  due  to, 
or  a  sequence  of,  chronic  cystitis.  It  consists  in  an  unusually  rapid 
formation  of  epithelium  by  the  vesical  mucous  membrane,  resulting 
in  the  shedding  of  quite  large  white,  shining  plates  or  bodies  of  this 
caked  scale.  The  following  case,  related  by  Lowenson  (1862),  is 
thus  given  by  Winckel.  The  patient  spoken  of  by  him,  suffered 
from  mitral  stenosis,  and  came  into  hospital  in  a  moribund  condition. 
After  death  her  bladder  was  found  to  be  enormously  dilated.  From 
it  were  taken  a  great  number  of  small,  rounded  yellow  masses,  lying 
between  a  number  of  plates  of  dullish  color,  the  general  appearance 
being  that  of  yellow  pea-soup,  with  some  of  the  hulls  left  in.  The 
whole  of  the  internal  surface  of  the  bladder  was  covered  with  flakes, 
many  of  them  having  these  little  balls  interposed  and  superimposed. 
Their  diameter  varied  from  one  twenty-fifth  to  one  half  inch.  These 
attached  flakes  were  tolerably  firm  and  bright,  something  like  mother- 
of-pearl.  From  the  mucous  membrane  itself,  after  removal  of  these 
flakes,  pieces  of  membrane  could  be  stripped  off.  Except  in  these 
places  the  mucous  membrane  seemed  normal.  The  urethra  and 
ureters  were  normal,  but  the  kidneys  were  in  a  condition  of  granu- 
lar atrophy. 

On  microscopic  examination  it  was  found  that  the  young,  often- 
times fatty  degenerated  epithelial  cells  (in  the  commencement),  as 
they  approached  the  surface,  took  on  gradually  all  the  changes  of 
the  very  large  epidermic  cell,  becoming  non-nucleated  and  granular. 
The  little  balls  consisted  of  grains  of  fat,  calciform  concretions,  lit- 
tle nuclei,  and  epidermic  cells.  There  was  considerable  stearine  but 
no  cholesterine.  Reich  claims  lately,  however,  to  have  found  the 
latter  in  the  vesical  mucous  membrane  of  a  man  flfty-six  years  old, 
who  suffered  from  catarrh  of  the  bladder. 

Treatment. — Of  course  I  have  no  experience,  never  having  seen 
a  case,  but  on  general  principles  I  would  suggest  that  the  treatment 
would  be  to  relieve  any  inflammation  or  irritation  that  may  be  pres- 
ent, the  exhibition  of  alkalies  and  arsenic  (in  small  doses)  by  the 
mouth,  daily  washing  out  of  the  bladder,  removing  all  scales  or 
plates  that  form,  and  the  application  of  a  strong  alkaline  solution  to 
the  diseased  surface. 

I  am  unable  to  give  the  symptoms  of  this  disease.  The  same  may 
be  said  of  the  diagnosis.  I  presume,  however,  that  an  examination 
of  the  urine  would  enable  one  to  determine  the  nature  of  the  trouble. 


CHAPTER   XLIV. 

NON-INFLAMltfATORY   DISEASES    OF    THE    BLADDEK. 
DISLOCATION  OF  THE  BLADDER. 

II,  Non-mflammatory  diseases  of  the  bladder.     These  are : 

1.  Dislocations. 

2.  Foreign  bodies. 

3.  Rupture. 

1.  Dislocations. — These  may  be  of  six  kinds :  {a)  upward ;  (h) 
backward ;  (c)  forward ;  {d)  lateral ;  {e)  downward ;  in  addition  to 
these,  we  may  have  {f)  inversion  of  the  bladder. 

Some  of  these  are,  even  in  their  worst  form,  not  tme  disloca- 
tions, but  represent  some  hindrance  to  the  proper  distention  of  the 
organ  or  its  position  when  distended.  Of  all  dislocations,  the  most 
important  are  the  upward,  backward,  and  downward.  All  of  them, 
however,  interfere  more  or  less  with  the  vesical  function.  Marked 
dislocation  of  a  healthy  bladder  often  gives  rise  to  less  disturbance 
than  slight  dislocation  of  an  already  irritable  organ. 

Dislocations  of  the  bladder  have  various  causes,  the  most  com- 
mon and  troublesome  being  abnormalities  of  structure  and  position 
of  the  uterus  and  vagina. 

As  a  matter  of  fact,  these  dislocations  are  usually  secondary  to 
some  aifection  of  the  other  pelvic  organs.  This  necessitates  a  de- 
scription of  their  causes  as  well  as  the  conditions  under  which  they 
occur,  thus  deviating  from  the  general  order  followed  in  this  work. 

{a)  Dislocation  Upward. — The  upward  dislocation  of  the  bladder 
may  be  caused  by  the  dragging  up  of  the  organ  by  the  gradual  rising 
from  the  pelvis  of  the  gravid  uterus.  This,  however,  is  a  rare  aifec- 
tion, and  only  occurs,  I  think,  in  cases  where  there  has  ])een  previous 
inflammatory  action  in  the  pelvis,  gluing  the  parts  together.  In 
most  pregnancies  the  bladder  retains  what  is,  under  the  circum- 
stances, its  normal  position.     Bands  of  adhesion  passing  from  the 

812 


NON-INFLAMMATORY  DISEASES   OF  THE   BLADDER.       813 

bladder  to  tlie  various  abdominal  and  pelvic  viscera  may,  when  short- 
ening takes  place,  produce  this  dislocation.  It  may  also  be  produced 
by  ovarian  tumors,  and,  in  some  cases  of  uterine  retroflexion  and 
retroversion.  The  dislocation  accompanying  the  last  two  affections 
is,  however,  usually  more  backward  than  upward. 

The  other  most  probable  causes  are  tamors  about  the  neck  or 
base  of  the  organ,  tumors  of  the  cervix  uteri,  pelvic  deformities,  and 
pelvic  exostoses. 

The  symptoms  are  usually  those  of  irritable  bladder.  In  some 
cases  of  pelvic  tumor  the  pressure  on  the  neck  of  the  bladder,  forc- 
ing it  against  the  pubes,  produces  retention.  This  is  purely  me- 
chanical. In  other  cases,  where  there  is  no  obstruction  to  the  out- 
flow, but  pressure  on  the  bladder,  there  may  be  incontinence ;  and, 
again,  from  traction  on  the  muscular  walls,  patients  are  unable  to 
contract  and  expel  the  vesical  contents,  and  retention  results. 

I  saw  a  case,  in  consultation  with  Dr.  A.  W.  Ford,  of  Brooklyn, 
in  which  the  patient  had  retention  of  urine,  so  that  she  could  not 
urinate  while  standing,  but  was  compelled  to  lie  down  before  the 
bladder  could  be  emptied.  The  retention  lasted  one  week,  and  was 
brought  on  by  the  efforts  to  urinate,  which  wedged  the  uterus  in  the 
pelvis,  and  compressed  the  neck  of  the  bladder.  She  was  relieved 
by  urinating  while  on  the  hands  and  knees. 

(5)  Dislocation  Backward. — This  dislocation  stands  next  in  order 
of  importance  and  unfavorable  results  to  downward  dislocation.  It 
may  be  caused  by  tumors  of  the  abdomen  or  by  pelvic  adhesions,  but 
the  most  frequent  cause  is  backward  dislocation  of  the  uterus,  such 
as  retroflexion  and  retroversion.  Retroversion  affects  the  bladder 
in  the  same  manner  as  prolapsus,  except  when  the  uterus  is  very 
much  enlarged,  and  is  thrown  backward  and  impacted  in  the  pelvis, 
so  that  the  cervix  presses  flrmly  on  the  urethra.  In  such  cases  urina- 
tion is  impossible.  Examples  of  this  are  seen  in  retroversion,  occur- 
ring in  the  early  months  of  pregnancy  or  after  delivery.  Schatz  gives 
a  case  due  to  retroflexion  of  the  uterus  during  pregnancy,  produc- 
ing the  same  trouble  in  the  bladder  as  retroversion. 

Winckel  saw  a  case  in  the  body  of  a  non-puerperal  woman,  in 
which  the  uterus  was  lying  almost  horizontally  in  the  pelvis,  with 
its  fundus  adherent  to  the  rectum.  That  part  of  the  bladder  that 
was  drawn  most  backward  had  a  diverticulum,  containing  a  calcu- 
lus. The  neck  of  the  bladder  was  fastened  down  posteriorly  by 
tight  bands  of  adhesion  that  passed  from  it  over  the  uterus  to  the 
rectum. 

In  retro-displacements  of  the  bladder,  with  no  pressure  on  the 


814 


DISEASES   OF   WOMEN^. 


vesical  neck,  the  symptoms  are  usually  those  of  irritation,  causing 

frequent  urination  and  tenesmus. 

I  give  here  the  following  cases,  as  they  are  of   interest,  and 

may  serve  to  fix  more  clear- 
ly in  the  mind  the  general 
points. 


ILLUSTRATIVE    CASES. 

The  first  is  a  case  of 
chronic  retroversion  of  the 
uterus,  causing  marked  vesi- 
cal trouble  in  a  nervous  wom- 
an. The  cause  of  the  blad- 
der trouble  is  here  double : 
■P  ^    oaK      T>  *         •        e  ^v,  -A    ^        first,    vesical    neurosis,    and 

i!iG.    265.  —  Ketroversion    of   the   gravid   uterus  '  ,  ' 

(after  Schatz).     The  bladder  pulled  upward  SeCOnd,  a  displaced  UteruS. 
and  backward,  and  the  urethra,  u,  put  great-  lur         rr  ^    |T^-  x       • 

ly  upon  the  stretch.  ^^^'^^-  "->    ^S^^   imrt}-SlX. 

Married  five  years,  and  a 
vridow  three  years,  of  a  marked  nervous  temperament.  Has  never 
been  pregnant.  Menstruation  always  normal,  and  general  health  fair 
in  early  life.  Her  general  system  has  been  much  reduced  by  nursing 
her  husband,  who  died  of  phthisis.  Nervous  system  also  much  im- 
paired. When  first  seen,  all  the  functions  except  those  of  the  blad- 
der were  performed  well.  She  suilered  night  and  day  from  frequent 
urination,  but  there  was  no  pain  either  during  or  after  the  act,  unless 
she  tried  to  hold  her  water  for  a  few  hours,  when  there  was  great  pain 
after  the  completion  of  evacuation.  Nervous  excitement,  pleasant 
or  unpleasant,  made  the  trouble  much  worse.    Her  urine  was  normal. 

On  examination,  complete  retroversion  of  the  uterus  was  found, 
with  shortening  of  the  anterior  vaginal  wall ;  the  bladder  was  much 
contracted,  but  otherwise  normal.  The  uterus  was  restored  to  its 
place,  and  held  there  by  a  pessary.  Hydrobromic  acid  in  thirty-min- 
im doses  was  given  four  times  a  day.     She  made  a  rapid  recovery. 

The  next  is  a  case  of  vesical  tenesmus  and  partial  retention  from 
a  sudden  retroversion  of  the  uterus. 

Mrs.  G.,  aged  forty-three,  the  mother  of  four  children.  "Widow 
for  several  years.  She  was  a  strong,  healthy  lady,  and  had  been  on 
her  feet  all  day  attending  to  her  household  duties,  and  in  the  even- 
ing, while  hanging  some  pictures,  slipped  from  a  chair,  and  fell 
heavily  to  the  floor,  striking  on  her  feet.  She  was  at  once  seized 
with  a  desire  to  urinate,  and  soon  after  pelvic  tenesmus  came  on. 
The   desire  to   urinate   was   constant,  and,  after  strong   expulsive 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.        815 

efforts,  she  was  able  to  pass  a  little  urine  from  time  to  time,  but 
without  relief.  The  bowels  became  distended  and  tympanitic.  On 
the  following  day  she  was  ordered  anodynes,  but  they  gave  very 
little  relief. 

On  the  next  day  she  was  examined,  and  the  uterus  was  found  to 
be  completely  retroverted,  and  the  bladder  full,  but  not  overdis- 
tended.  Replacing  the  uterus  gave  her  great  relief  at  once,  and  she 
has  remained  well  and  free  from  all  bladder  trouble  since  the  acci- 
dent occurred,  some  two  years  ago.  This  was  a  case  of  acute  retro- 
version of  the  uterus,  producing  an  intensely  painful  affection  in  a 
normal  bladder. 

(c)  Dislocation  Forward. — Forward  dislocation  of  the  bladder, 
unless  it  be  through  the  open  abdominal  walls,  is  very  rare.  Some 
change  in  its  shape  from  pressure  of  organs  or  tumors  from  behind 
may  occur,  but  this  is  really  not  a  true  displacement,  except  in  some 
rare  and  marked  cases.  The  most  frequent  cause  is  pressure  from 
the  anteverted  and  enlarged  utei-us  in  either  the  virgin  or  puerperal 
state.  Anteversion  of  the  uterus  usually  causes  frequent  urination, 
perhaps  as  much  so  as  prolapsus ;  but  whether  this  frequency  is  due 
to  the  fundus  uteri  resting  on  the  bladder,  or  to  the  supersensitive- 
ness  of  the  whole  pelvic  organs,  which  usually  accompanies  this  dis- 
location, I  have  not  always  been  able  to  determine.  I  have  been  in- 
clined to  the  belief  that  the  latter  was  the  case.  In  this  displace- 
ment (anteversion)  the  uterus  is  generally  enlarged  and  elevated,  so 
that  the  body  and  fundus  rest  upon  the  bladder,  and  impede  its  dis- 
tention. 

True  dislocation  of  the  bladder  forward  is  the  rarest  of  all  dis- 
locations, only  three  cases  being  on  record.  It  has  been  variously 
called  ectopia  of  the  unfissured  bladder,  ectopia  vesicae  totalis,  and 
prolapsus  vesicae  completus  per  iissuram  tegumentorum  abdominis. 
The  first  name  is  too  vague,  the  last  best  of  all,  but  rather  lengthy 
for  every-day  use. 

The  three  cases  on  record  are  by  O.  Yrolik,  Stoll,  and  Lichten- 
heim.  In  aU  these  the  bladder  was  protruded  through  a  small  slit 
in  the  abdominal  wall,  and  appeared  as  a  bright-red,  rounded  tumor 
at  the  lower  and  anterior  part  of  the  abdomen.  In  Lichtenheim's 
case  only  was  the  tumor  reducible.  The  pubic  bones  were  separated 
about  two  inches.  The  urine  could  be  retained  perfectly,  and  the 
patient  was  able  to  micturate  in  a  small  stream.  Microscopical  ex- 
amination of  the  outer  covering  of  the  bladder-walls  proved  it  to  be 
mucous  membrane,  Uke  that  lining  the  interior  of  the  organ. 

In  G.  Yrolik's  case,  according  to  Winckel,  there  is  doubt  as  to 


816  DISEASES   OF   WOMEN. 

whether  it  was  a  true  vesical  ectopia.  He  believes  it  to  have  been 
a  gaping  of  the  fissured  abdominal  walls  over  a  dilated  urachus,  the 
latter  communicating  with  the  bladder  by  a  small  oi3ening. 

In  Lichtenheim's  patient  no  operative  measures  were  thought  of, 
for,  beyond  a  little  excessive  secretion  of  the  external  surface,  no 
trouble  was  experienced.  If,  however,  from  the  protrusion  of  the 
tumor  or  other  cause,  difficulty  in  passing  or  retaining  urine  be  pres- 
ent, an  attempt  should  be  made  to  close  the  abdominal  fissure.  If 
it  be  large,  two  or  more  flaps  may  be  needed  to  accomplish  the  de- 
sired result.  The  operation  is  very  like  that  for  fissure,  already  de- 
scribed, only  more  simple. 

If  an  operation  is  not  desired  or  consented  to,  the  patient  should 
wear  a  concave  compress,  and,  by  attention  to  bandaging,  keep  the 
surface  of  the  organ  in  as  nearly  a  normal  condition  as  possible. 

id)  Lateral  Displacements. — Lateral  displacement  of  the  bladder 
is  not  very  often  met  with.  It  is  generally  due  to  inguinal  or  fem- 
oral hernia,  tumors  at  the  side  and  base  of  the  organ,  arid  contract- 
ing pelvic  adhesions.  There  is  generally  more  or  less  distortion  of 
the  urethra  that  may  hinder  the  outflow  of  urine  or  prevent  the  easy 
introduction  of  a  catheter.  Irritability  may  result,  but  it  is  not  so 
common  as  in  the  other  varieties,  the  organ  being  generally  but 
slightly  displaced,  and,  soon  getting  used  to  the  disturbing  cause 
arising  from  the  malposition,  produces  but  little  disturbance. 

One  case  of  this  kind  I  have  seen  which  was  of  interest.  The 
patient  was  a  young  lady,  who  had  had  a  pelvic  peritonitis,  which 
left  her  with  pelvic  tenesmus,  ovarian  pain,  and  some  vesical  tenes- 
mus and  difficulty  in  emptying  the  bladder.  One  of  my  assistants, 
while  examining  her,  found  a  fluctuating  tumor  on  the  left  side, 
which  he  supposed  to  be  an  ovarian  cyst,  but  which  proved  to  be 
a  left  lateral  displacement  of  the  bladder  fixed  in  its  malposition  by 
adhesions. 

Causation. — Its  causes  are  of  two  kinds — predisposing  and  excit- 
ing. Of  the  predisposing,  the  most  common  are  a  loose,  flabby  con- 
dition of  the  vesico-vaginal  septum,  excessive  venositj^  of  same  (these 
may  be  due  to  pregnancy  or  to  a  general  systemic  condition),  ab- 
normally capacious  vagina,  unusually  large  introitus  vagina?,  total  or 
partial  loss  of  perineal  body,  and  the  tendency  of  the  bladder  to 
pouch  inferiorly  as  age  advances. 

As  exciting  causes,  we  have  violent  expulsive  efforts,  as  in  def- 
ecation, lifting  heavy  weights,  and  especially  child-bearing.  The 
latter  is  probably  one  of  its  most  common  causes,  for  not  only  do 
we  have  expulsive  efforts  of  the  most  violent  kind,  but  a  lax,  spongy 


NON-INFLAMMATORY  DISEASES   OF  THE   BLADDER.       817 

condition  of  the  vesico- vaginal  septum — i.  e.,  the  anterior  vaginal 
and  posterior  vesical  walls,  which  are  pushed  downward  before  the 
advancing  head. 

Another  common  cause  is  prolapsus  uteri,  though  in  many  cases 
the  cystocele  precedes  the  prolapse  of  the  womb.  Whichever  is 
the  cause,  the  one  aggravates  the  other.  In  slight  prolapse  of  the 
uterus,  the  vesical  symptoms  are  only  those  of  irritation ;  and  it  is 
a  strange  fact  that  the  irritation  is  often  as  great  in  the  first  degree 
of  prolapse  as  in  the  third. 

Other  less  frequent  causes  of  cystocele  may  be  tumors  in  the 
posterior  vesical  or  anterior  vaginal  wall,  stone  in  the  bladder,  vesi- 
cal diverticuli,  violent  efforts  at  urination,  and  marked  pressure  fi'om 
above. 

The  bladder  begins  to  sag  inferiorly  as  age  advances,  and  conse- 
quently the  tendency  to  prolapsus  advances,  as  does  the  age.  The 
number  of  pregnancies  may,  ho-wever,  have  more  to  do  with  the  fre- 
quency than  the  tendency  to  pouching  in  old  age. 

{e)  Dislocation  Downward. — I  have  reserved  this  malposition  to 
the  last,  because  it  is  the  most  important.  There  are  various  grades 
of  the  dislocation,  the  most  marked  of  which  is  known  as  cystocele 
vaginalis. 

Pathology. — This  affection  may  be  conveniently  divided  into 
three  grades.  In  the  first,  there  is  but  a  slight  bagging  of  the  or- 
gan. In  the  second,  about  one  half  the  bladder  lies  below  the  nor- 
mal level  of  the  anterior  vaginal  wall,  giving  the  organ  an  hour- 
glass shape,  the  urethra  entering  the  upper  segment  just  above  the 
point  of  partial  constriction.  In  the  third  or  highest  grade,  the 
whole  bladder  lies  below  the  level  of  the  normal  anterior  vaginal 
wall.  The  urethra  in  these  cases  has  a  direction  from  above  back- 
ward and  downward.  The  ureters  in  the  last  two  grades  are  so  bent 
and  obstructed  by  pressure,  that  dilatation  and  hydronephrosis  may 
result.  Such  instances  are  given  by  Phillips,  Froreiss,  Yirchow, 
Braun,  and  Winckel. 

The  vesico-uterine  pouch  is,  in  cases  of  marked  vesical  and 
uterine  jDrolapse,  greatly  increased  in  size,  and  may  contain  a  loop  of 
intestine.  In  some  rare  cases  it  may  become  constricted  superiorly, 
and  exist  as  a  closed  sac. 

In  chronic  cases  the  vesical  mucous  membrane  becomes  hyper- 
trophied,  and,  in  the  lower  segment  especially,  congested  and  cedem- 
atous.  To  this  may  be  superadded  cystitis  and  ulceration,  which 
often  follow  in  cases  of  long  standing. 

Symptomatology. — In  the  first  grade  of  downward  dislocation 
53 


818  DISEASES  OF   WOMEN. 

the  symptoms  are  those  of  irritable  bladder,  such  as  frequent  and 
sometimes  painful  urination.  When  the  displacement  has  existed 
for  a  considerable  time,  the  bladder  seems  to  accommodate  itself  to 
the  new  relations,  and  the  calls  to  urinate  become  less  frequent.  In 
cases  in  which  the  prolapsus  of  the  bladder  is  slight  and  there  is  dila- 
tation or  prolapsus  of  the  upper  third  of  the  urethra,  partial  inconti- 
nence occurs,  a  very  annoying  symptom.  Every  time  the  patient 
coughs,  lifts  a  heavy  weight,  steps  suddenly  down  from  the  curb- 
stone into  the  street,  or  even  indulges  in  a  hearty  laugh,  there  is  a 
sudden  escape  of  urine. 

In  complete  prolapsus  of  the  utei-us  and  bladder,  we  find  instead 
of  frequent  urination,  difficult  urination,  and  in  the  worst  cases,  re- 
tention. Partial  retention  always  occurs  in  the  marked  cases,  and 
the  urine  remaining  in  the  bladder  decomposes,  and  in  time  causes 
cystitis,  which  greatly  aggravates  the  patient's  sufferings.  Such 
cases  are  very  like  those  occurring  in  old  men,  and  due  to  retained 
urine  by  reason  of  an  enlarged  prostate  gland. 

There  is  usually  a  dragging  pain  experienced  in  the  region  of 
the  umbilicus,  which  is  due  to  traction  on  the  urachal  cord,  and  also 
a  constant  sense  of  pain  and  uneasiness,  due  partly  to  the  vesical  and 
partly  to  the  uterine  malposition. 

To  fully  empty  the  bladder  in  the  worst  cases,  it  is  necessary  to 
relax  the  parts  by  lying  down,  and  then  force  out  the  urine  by  press- 
ure on  the  vaginal  tumor. 

Cystitis  is  a  common  secondary  affection,  and  is  due  to  decompo- 
sition of  the  retained  urine,  and  to  chronic  congestion  with  oedema 
and  hypertrophy  of  the  mucous  membrane.  Winckel's  experience 
has,  however,  differed  from  that  of  most  observers,  he  having 
failed  to  find  a  single  instance  of  cystitis  in  sixty-eight  cases  of  cys- 
tocele. 

From  pressure  on  the  ureters  there  may  result  dilatation  and 
hydronephrosis,  and  if  marked  or  long-continued,  uraemia.  There 
may  also  be  set  up  that  condition  known  as  pericystitis,  and  the 
lower  vesical  segment  be  rendered  irreducible  owing  to  the  formation 
of  adhesions. 

If  cystocele  occurs  in  a  patient  already  suffering  from  cystitis, 
the  original  trouble  is  of  course  greatly  aggravated. 

Cystocele  may  interfere  with  delivery  during  childbirth.  In 
one  such  case,  McKee,  being  unable  to  push  a  catheter  into  the 
bladder,  punctured  the  tumor  with  a  lancet,  and  dehvery  was  rap- 
idly accomplished.  In  another  case,  a  certain  physician  mistook 
the  vesical  tumor  for  the  bag  of  waters,  and  punctured  it. 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER.       819 

Diagnosis. — This  is  readily  made.  The  patient  should  be  laid 
upon  her  back,  with  the  thighs  flexed  on  the  body.  If  the  tumor  is 
already  down  it  should  be  examined  carefully,  and  also  the  position 
and  condition  of  the  neighboring  organs.  If  possible,  a  catheter 
should  be  passed  into  the  bladder,  to  ascertain  if  it  enters  the  tumor 
and  the  direction  it  takes  in  so  doing  should  be  ol)served.  The 
tumor  should  be  slightly  compressed,  and  notice  taken  whether  the 
urine  flows  from  it  through  the  catheter.  An  attempt  should  also 
be  made  to  try  to  reduce  it.  The  urine  should  be  carefully  ex- 
amined for  pus,  mucus,  albumen,  epithelial  elements,  and  the  amount 
of  urea  should  be  determined. 

Prognosis. — The  prognosis  is  generally  good  ;  but  in  giving  an 
opinion  the  degree  of  dislocation,  the  size  of  the  tumor,  the  condi- 
tion of  its  mucous  membrane,  whether  it  is  reducible  or  not,  the 
age  of  the  patient,  and  the  gravity  of  the  producing  cause,  must  all 
be  taken  into  consideration. 

In  young  patients,  Sims,  Simon,  Hegar,  Verf,  and  others  claim 
to  have  obtained  radical  cures.  Some  of  these  cures  were  not,  how- 
ever, lasting.  Scanzoni  claimed  that  he  had  never  seen  an  opera- 
tion for  this  displacement  that  resulted  in  a  permanent  success,  and 
that  his  own  operations  were  by  no  means  satisfactory.  My  own 
experience  entirely  accords  with  that  of  Scanzoni. 

Treatment. — The  treatment  consists  in  reposition  and  retention. 
The  former  is  easy,  the  latter  hard  to  accomplish,  as  prolapsus  uteri 
and  cystocele  generally  go  hand  in  hand ;  one  can  not  be  treated 
without  the  other. 

Having  pushed  the  uterus  up  into  position,  emptied  the  bladder 
and  replaced  it,  some  mechanical  ^^^^^^ 

means  should  be  sought  to  retain  /^^^^^^ 

one  or  both  organs  in  place,  im^W^^^^ 

For  the  purpose  of  support-       >^^^^^      fW^t      ^H^^ 
ing  the  prolapsed  bladder  I  de-     wm^         -^^^^yy^^        '"^■"8^^ 
vised  the  pessary  shown  in  Fig.     ^t^      "  ^-<(^^^^^^^^^*^^ 
266,   and  it  has  been  found  to      ^^^^^S^^ 
accomplish  the  obiect  fairly  well    ^i^-  J^^--^^f  ^^'y,  for  prolapsus  of  the 

^  1    •        1  •  •  bladder  (Skene).     1  he  main  portion,  a, 

when   the   pelvic   floor   is   not  m-  surrounds  the  cervix  uteri,  and  b  sup- 

inred  ports  the  bladder  and  upper  portion  of 

J  '  ,  the  urethra.     The  other  part,  c  c,  joins 

This   pessary  is    adapted    and  the  main  portion  in  front  of  the  uterus, 

introduced    in  the  same  way  as  a  and  rests  on  the  posterior  walls  of  the 

•^  vagina. 

retroversion  pessary,  an  account 

of  which  will  be  found  under  the  head  of  the  treatment  of  retro- 
version. 


820 


DISEASES  OF  WOMEN. 


The  facility  of  introduction  and  removal  is  one  of  the  minor,  but 
by  no  means  unimportant,  qualities  of  this  pessary. 

Several  sizes  are  made,  wliich  answer  in  most  of  the  forms  of 
displacement  of  the  bladder ;  but  a  case  will  occasionally  occur  in 
which  it  is  necessary  to  hrst  take  measurements,  and  have  the  in- 


FiG.  267. — Pessary  holding  up  the  bladder. 

strument  made  exactly  to  suit.  This  can  be  easily  done.  The  pa- 
tient is  placed  on  her  left  side,  and  after  introducing  the  speculum, 
the  uterus  and  bladder  are  restored  to  their  proper  positions  ;  then 
a  thin  strip  of  sheet  lead  is  bent  to  the  size  and  shape  of  the  ante- 
rior walls  of  the  vagina  and  cervix  uteri.  This  form  will  enable  the 
instrument-maker  to  produce  the  required  size  and  shape  of  the 
pessary.  I  have  also  devised  another  form  which  suits  some  cases. 
It  is  like  the  retroversion  pessary 
which  I  use,  but  the  sides  anteriorly 
are  made  more  curved  and  very 
much  thicker  than,  the  ordinary  one, 
Fig.  208. 

Should  a  pessary  fail  to  accom- 
plish the  desired  result  and  the  case 
grow  gradually  worse  and  the  de-    ^'»-  2fi8.-Modification  of  the  retrover- 
J  7         T    /'•  1  *^'""  pessary,  used  in  prolapsus  oi 

mand  lor  reliei  become  more  urgent,  the  bladder. 


NON-INFLAMMATORY  DISEASES  OF   THE  BLADDER.         821 

the  operation  may  be  performed  whicli  is  described  on  page  925 
and  illustrated  in  Fig.  281,  Plate  IV. 

HERNIA    OF    THE    BLADDER. 

This  injury  was  first  recognized  by  Dr.  Taul  F.  Munde,  and 
described  by  him  in  the  "  American  Journal  of  Obstetrics,"  June, 
1890,  page  614.  That  it  may  have  been  observed  by  others  is  pos- 
sible, but  it  was  evidently  not  understood  until  thoroughly  investi- 
gated by  Munde.  Guided  by  the  light  which  he  has  thrown  upon 
tlie  subject,  I  have  been  able  to  comprehend  a  number  of  cases 
which  were  previously  obscure,  and  which,  not  knowing  better,  I 
had  classified  as  cases  of  prolapsus  of  the  bladder. 

The  pathology  is  the  same  as  in  all  hernial  protrusions.  There 
is  first  a  giving  way  of  the  anterior  muscular  wall  of  the  vagina  in 
the  median  hne,  and  then  the  bladder,  covered  only  with  the  vagi- 
nal mucous  membrane,  protrudes  into  the  vagina. 

Ccmsation. — There  are  three  causes  which  I  have  observed  in 
the  cases  which  have  come  under  my  observation  : 

The  first,  which  occurs  less  commonly  now  than  formerly,  is 
removal  of  a  part  of  the  vaginal  wall,  colporrhaphy.  In  time  the 
scar-tissue  stretches  at  the  site  of  the  operation,  and  the  bladder 
protrudes  at  the  point  at  which  muscular  tissue  is  deficient. 

The  second  cause  is,  apparently,  a  laceration  of  the  muscular 
tissue  in  the  median  line  during  labor.  When  the  hernia  is  caused 
in  this  way  the  urethra  and  lateral  walls  are  in  proper  position,  but 
at  the  point  of  hernia  the  muscular  tissue  and  fascia  are  absent. 

The  remaining  cause  is  atrophy  of  the  muscular  tissue.  This  I 
believe  to  occur,  because  it  has  been  found  in  women  past  the  meno- 
pause who  have  not  had  children,  and  who  have  not  been  subjected 
to  any  injury  which  could  have  produced  muscular  laceration. 

Syinptotnatology. — The  symptoms,  so  far  as  I  have  observed 
them,  are  the  same  as  in  prolapsus  of  the  bladder. 

Physical  Signs. — The  physical  signs  are,  when  understood,  quite 
diagnostic.  When  the  perinaeum  is  retracted,  the  hernia  appears  as 
a  smooth,  hemispherical  body,  around  the  base  of  which  the  vaginal 
walls  are  in  normal  position.  With  a  sound  in  the  bladder,  the  thin 
vaginal  wall,  which  is  reduced  to  mucous  membrane  only,  is  appar- 
ent to  the  touch.  If  any  doubt  exist  about  the  diagnosis,  the  results 
of  treatment  will  determine  whether  the  condition  is  that  of  hernia 
or  of  prolapse.  If  it  be  a  prolapsus,  which  has  been  treated  by  the 
use  of  a  tampon  or  pessary,  witli  rest  in  a  recumbent  position,  there 
will  be  a  noticeable  contraction  of  the  vaginal  wall  and  a  temporary 


822  DISEASES   OF  WOMEN. 

relief ;  but  no  such  change  occurs  as  a  result  of  this  treatment  in 
case  of  hernia. 

Treatment. — Having  failed  to  relieve  hernia  by  any  of  the  oper- 
ations recommended  for  prolapse,  I  was  driven  to  try  an  operation 
which  gave  me  good  results,  and  that,  too,  before  I  understood  the 
true  pathology  of  the  aifection. 

The  operation  consists  in  making  a  small  opening  in  the  vaginal 
wall  at  the  junction  of  the  urethra  and  bladder,  and  at  the  lower 
margin  of  the  hernia.  Through  this  opening  a  probe  is  passed  and 
pushed  up  to  the  upper  margin  of  the  hernia,  between  the  vaginal 
wall  and  the  bladder.  A  delicate  forceps  is  then  introduced  into 
the  tunnel  made  by  the  probe,  and  its  blades  are  spread  forcibly 
apart.  The  vaginal  wall  and  bladder  are  then  completely  separated 
to  the  extent  of  the  hernial  opening  in  the  muscular  layer  of  tlie 
vagina.  The  probe  or  forceps  is  held  in  place  and  upward  j^ressure 
is  made  with  it.  This  keeps  the  bladder  in  place  while  traction  is 
made  upon  the  vaginal  mucous  membrane  at  its  upper  part.  This 
brings  the  lateral  edges  of  the  muscular  layer  of  the  vagina  together 
and  develops  a  ridge  of  mucous  membrane.  Sutures  are  now  intro- 
duced to  hold  the  parts  in  position. 

The  mechanism  of  this  proceeding  is  the  same  as  in  making  a 
tuck.  The  ridge  or  tuck  of  mucous  membrane  projects  into  the 
vagina  like  the  segment  of  a  circle,  but  soon  flattens  out  and  over- 
hang's the  line  of  sutures.  Care  should  be  taken  not  to  make  the 
sutures  tight  enough  to  strangle  the  tissues,  but  only  sufficiently  so  to 
hold  them  together  until  they  unite.  I  have  operated  in  a  number 
of  cases,  and  the  immediate  results  are  all  that  could  be  desired.  I 
have  had  an  opportunity  to  observe  but  four  cases  long  enough  to 
determine  whether  the  cui-e  is  permanent  or  not.  In  one  of  these, 
done  five  years  ago,  the  hernia  shows  no  disposition  to  return.  The 
same  is  true  of  all  the  cases  that  I  have  operated  upon.  The  first 
operation  was  done  five  years  ago,  and  the  last,  one  year. 

Dr.  Munde,  in  his  paper  on  this  subject,  commends  the  opera- 
tion of  Stolz,  which  consists  in  the  removal  of  the  circular  portion 
of  the  mucous  membrane  which  covers  the  hernia,  and  the  bring- 
ing of  the  parts  together  at  one  central  point  Math  a  purse-string 
suture. 

I  have  tried  this  operation  in  three  cases,  and  have  found  that, 
while  it  appeared  to  answer  the  purpose,  the  scar  gave  way  in  time 
and  the  hernia  returned.  In  fact,  the  worst  case  of  hernia  of  the 
bladder  that  I  ever  saw  followed  a  similar  operation,  which  was 
done  for  prola^jsus. 


NON-INFLAMMATORY  DISEASES  OF   THE  BLADDER.        §23 
ILLUSTRATIVE    CASES. 

A  patient  who  had  had  a  number  of  children  suffered  from 
a  prolapse  of  the  bladder  and  laceration  of  the  perinaBum.  I 
performed  Noeggerath's  operation  for  the  relief  of  cystocele,  and 
obtained  a  good  result  so  far  as  relieving  her  for  a  time.  She 
returned  four  years  afterward,  suffering  as  much  as  ever.  I 
found  that  the  scar  left  after  removing  the  section  of  the  an- 
terior vaginal  wall  had  become  stretched  and  thinned  out,  so  that 
the  bladder  protruded.  I  vivified  the  vaginal  wall  all  around 
the  outer  edge  of  the  scar,  and  brought  the  surfaces  together 
and  obtained  good  union.  Two  years  after  this  I  found  the  her- 
nia had  again  returned.  This  led  me  to  devise  the  operation  which 
I  have  described  above,  and  which  has  given  me  far  more  satis- 
faction. 

Hernia  following  Stolz's  Operation. — A  patient  fifty-nine  years 
old  had  a  prolapsus  of  the  bladder  and  a  laceration  of  the  peri- 
nseum  of  sixteen  years'  standing.  I  performed  Stolz's  operation 
and  restored  the  perinseum.  She  was  apparently  cured,  but  two 
years  afterward  I  saw  her  again,  when  I  found  what  I  believed  to 
be  a  return  of  the  prolapsus,  but  I  now  know  that  she  had  a  vesical 
hernia. 

Frequent  TJrination  due  to  Prolapsus  of  the  Bladder. — The  patient 
was  thirty-two  years  old,  and  had  given  birth  to  five  children.  She 
had  always  been  well  and  strong,  and  at  the  time  that  I  saw  her 
she  was  in  very  good  general  health.  After  her  last  confinement, 
one  year  previous,  she  began  to  suffer  from  frequent  urination. 
At  first  she  obtained  relief  from  emptying  the  bladder,  but  subse- 
quently the  desire  to  urinate,  though  not  very  urgent,  was  constant 
when  she  was  upon  her  feet.  On  lying  down  she  obtained  relief 
and  retained  the  urine  all  night,  but  upon  rising  and  going  about 
the  tenesmus  returned. 

By  digital  examination  I  detected  a  prolapsus  of  the  bladder, 
but  only  in  a  slight  degree. 

There  was  considerable  relaxation  of  the  pelvic  floor  and  of 
the  vaginal  walls,  but  no  laceration  of  either.  In  all  other  respects 
she  was  quite  well.  The  urine  was  normal.  She  was  ordered  to 
rest  for  a  few  days,  most  of  the  time  reclining,  and  to  use  vaginal 
injections  night  and  morning  of  sulphate  of  zinc,  sixty  grains  to 
the  quart  of  warm  water.  Afterward  a  pessary  was  used  shaped 
like  Graily  Hewett's  anteversion  pessary,  but  having  the  anterior 
bars  thickened. 


824  DISEASES  OF   WOMEN. 

Immediate  relief  was  given  by  the  pessary,  and  she  was  able  to 
walk  and  stand  as  she  used  to  in  former  times.  The  zinc-douche 
was  kept  up  once  a  day,  and  she  was  cautioned  against  walking  or 
standing  too  long.  At  the  end  of  six  weeks  the  pessary  was  re- 
moved to  see  if  she  could  do  without  it.  In  a  few  days  the  old 
symptoms  began  to  return,  and  the  pessary  was  replaced  to  her  en- 
tire relief.  From  this  time  onward  the  pessary  was  changed  once  a 
month  for  a  smaller  one.  Seven  months  afterward  the  instrument 
was  removed,  and  the  injections  of  the  zinc  solution  continued  for 
one  month  longer.     She  had  no  fui-ther  trouble. 

Prolapsus  of  the  Bladder  caused  by  Laceration  of  the  Perinaeum. — 
This  lady  was  forty-one  years  old,  of  large  form,  and  had  an  excel- 
lent constitution  ;  she  had  two  daughters,  the  youngest  seven  years  of 
age.  For  nearly  six  years  she  had  suffered  from  vesical  tenesmus  and 
frequent  urination.  These  symptoms  were  greatly  aggravated  by 
the  erect  position.  In  fact,  for  a  long  time  she  was  quite  comfort- 
able while  sitting  or  lying  down,  especially  the  latter.  Her  symp- 
toms gradually  increased,  and  within  the  past  two  years  she  has  had 
partial  incontinence.  Any  sudden  motion  such  as  is  caused  by  cry- 
ing or  sneezing  would  cause  a  spurt  of  urine  which  was  most  dis- 
tressing to  her.  She  became  quite  helpless  although  in  perfect 
health.  Bemg  unable  to  stand  or  walk  for  any  length  of  time  and 
having  partial  incontinence  she  remained  in  the  house  all  the  time. 
She  had  been  treated  with  all  kinds  of  drugs,  but,  as  might  have 
been  expected,  without  any  relief.  I  found  that  she  had  a  laceration 
of  the  perinaeum,  and  also  a  bilateral  laceration  of  the  cervix  uteri. 
The  bladder  was  prolapsed  and  the  upper  third  of  the  urethra  pre- 
sented the  usual  signs  of  the  ordinary  cystocele.  She  was  admitted 
to  my  private  hospital,  and  after  having  been  submitted  to  prepara- 
tory treatment  the  cervix  was  restored.  While  she  was  recovering 
from  that  operation  the  bladder  was  kept  in  place  by  the  tampon, 
and  astringent  vaginal  injections  were  used.  One  month  later  the 
pelvic  floor  was  restored,  and  as  much  tissue  brought  together  as  pos- 
sible. After  the  operation  the  pelvic  floor  was  kept  well  sup- 
ported with  a  compress  and  T-bandage.  The  astringent  injections 
were  continued.  Six  weeks  from  the  last  operation  she  was  per- 
mitted to  take  exercise,  but  the  pelvic  floor  was  supported  for  two 
months  longer.  After  restoring  the  pelvic  floor  it  was  necessary  to 
use  the  catheter  to  draw  the  urine ;  that  excited  some  irritation  of 
the  bladder,  but  this  was  relieved  by  injections  of  borax  and  water. 
She  made  a  perfect  recovery,  and  has  remained  quite  well  for  more 
than  four  years. 


NON-INFLAMMATORY  DISEASES   OF  THE   BLADDER.       825 

Cases  of  Displacement  of  the  Bladder  due  to  Displacement  of  the 
Uterus  and  Causing  Retention  of  TJrine. — (D.  Berry  Hart,  M.  D.,  "  Ob- 
stet.  Jour.,"  Great  Britain  and  Ireland,  August  3,  1880) : 

Case  I. — A.  B.,  aged  eighteen,  was  seen  in  Prof.  Simpson's  out- 
patient clinic,  on  account  of  white  discharge  and  pain  on  making 
water.  Ocular  examination  of  the  external  parts  showed  a  recent 
laceration  of  the  hymen  and  glairy  discharge  from  the  ostium  ^aginse. 
On  vaginal  examination  the  cervix  was  found  normal  in  all  respects, 
except  that  the  os  looked  downward  and  forward  ;  bimanually,  a  fluc- 
tuating tumor,  reaching  up  a  little  above  the  level  of  the  pelvic  brim, 
was  felt  in  front  of  the  partially  retroverted  unimpregnated  uterus. 
The  catheter  introduced  drew  off  twenty-seven  ounces  of  urine. 

Case  II, — Mrs.  C.  was  admitted  to  Prof.  Simpson's  ward  on  ac- 
count of  retention  of  urine,  necessitating  catheterism ;  bimanual  ex- 
amination showed  a  large  tumor  in  the  hollow  of  the  sacrum,  marked 
elevation  of  the  os  uteri  above  the  symphysis,  and  a  fluctuating  tumor 
in  the  hypogastric  region,  reaching  almost  as  high  as  the  umbilicus. 
This  physical  examination  and  the  history  of  four  months  amenor- 
rhoea  made  the  diagnosis  of  retroversion  of  the  gravid  uterus  per- 
fectly plain.  What  concerns  us  here,  however,  is  that  the  bladder 
contained  only  about  twenty-three  ounces  of  urine,  a  less  amount 
than  in  the  previous  instance. 

Case  III. — Along  vdth  Prof.  Simpson  I  saw  at  the  Maternity 
Hospital  a  patient  with  rigidity  of  os  uteri,  supposed  to  necessitate 
early  application  of  the  long  forceps ;  supra-j^ubic  inspection  and 
palpation  revealed  a  fluctuating  tumor  bluntly  triangular  in  shape, 
with  the  apex  down.  Exact  measurements  showed  that  vertically  it 
extended  four  inches,  and  transversely  for  about  the  same  distance. 
The  catheter  passed  deeply  up,  and  drew  off  only  two  ounces  and  a 
half  of  clear  urine,  and  some  time  afterward  the  same  apparent  dis- 
tention occurred,  when  three  ounces  and  a  half  were  removed.  Af- 
ter the  bladder  was  thus  emptied,  the  furrow  between  cervix  and 
uterus  could  be  felt  two  fingers'  breadth  above  the  symphysis  pubis. 
These  three  cases  are  typical  instances,  and  evidently  call  for  expla- 
nation. 

In  the  first  case  narrated  the  bladder  was  simply  distended.  It 
had  pushed  the  intestines  up,  tilted  the  uterus  back,  but  its  posterior 
wall  was  still  in  its  nonnal  position.  The  peritonaeum  was  still  on 
the  summit  of  the  bladder,  but,  of  course,  was  stripped  to  a  certain 
extent  from  the  lower  part  of  the  posterior  aspect  of  the  anterior 
abdominal  wall.  Thus  the  bladder,  though  its  summit  was  only  at 
the  level  of  the  brim,  was  considerably  distended.     Now,  in  the 


826  DISEASES   OF   WOMEN. 

retroversion  of  the  gravid  uterus,  the  bladder  was  certainly  distended, 
supra-pubic  palpation,  however,  misled  as  to  the  amount  of  disten- 
tion, and  for  the  following  reason  :  The  cervix  uteri  was  tilted 
high  up  behind  the  symphysis  pubis,  and  consequently  the  blad- 
der, to  whose  posterior  angle  the  cervix  is  attached,  was  swung 
up,  as  it  were,  into  the  abdominal  cavity,  a  movement  permitted  by 
the  anatomical  relations  behind  the  pubis.  The  peritoneal  relations 
were  the  same  as  in  Case  I.  In  the  third  case,  the  bladder  was,  of 
course,  drawn  up,  as  I  have  already  shown,*  and  its  relations  were  as 
follows :  In  front  it  touched  the  anterior  abdominal  wall ;  behind, 
the  child's  head,  the  cervix,  of  course,  intervening.  In  this  way  the 
anterior  and  posterior  vesical  walls  were  in  contact,  and  thus  a  film 
of  urine,  as  it  were,  gave  the  appearance  of  distention.  As  I  have 
before  pointed  out,  the  peritonaeum  is  stripped  off  the  bladder 
more  or  less.f 

The  conclusions  advanced  are  :  1.  The  retro-pubic  anatomical 
attachments  of  the  bladder  admit  of  its  distention  and  passage  up- 
ward. 2.  Supra-pubic  palpation  gives  no  sure  indication  of  the 
amount  of  urinary  distention.  3.  When  the  summit  of  the  blad- 
der is  above  the  pubis,  it  may  be  (a),  a  pure  distention  (Case  I) ;  (h), 
distention  plus  a  tilting  up  (Case  II) ;  (c),  drawing  up  of  the  blad- 
der, with  almost  no  distention  (Case  III). 

The  reason  why  gynecologists  use  a  long  gum-elastic  catheter  is 
very  evident.  I  have  already  described  the  empty  bladder  in  the  non- 
parturient  female  as  forming  a  Y-shaped  figure  on  vertical  section. 
During  parturition,  however,  the  urethra  is  elongated,  and  forms 
with  the  bladder,  on  vertical  section,  a  continuous  tube. :{;  Only 
that  part  of  the  bladder  above  the  pubis  is  available  for  the  recep- 
tion of  urine,  so  that  in  this  way  the  path  for  the  catheter  to  travel 
is  increased.  In  Braune's  section  of  a  woman  in  labor,  the  distance 
for  the  catheter  to  travel  is  about  four  and  a  half  inches,  more  than 
twice  what  it  is  normally. 

In  the  last  place,  the  distended  female  adult  bladder  is  quite 
comparable  in  its  anatomical  relations  to  the  distended  fetal  one. 
This  may  point  to  the  explanation  that  the  ultimate  changes  which 
convert  the  urinary  bladder  from  an  abdominal  organ  into  a  pelvic 
one  is  chiefly  in  the  l)ony  pelvis  itself. 

Retrocession  and  Forward  Transposition  of  the  Uterus. — The  vari- 
ous forms  of  displacement  of  the  l)ladder  described  thus  far,  ai'e  usu- 

*  "Edinburgh  Medical  Journal,"  April,  1879. 

f  "Edinburgh  Medical  Journal,"  September,  1879,  "Edinburgh  Obstetrical  Transac- 
tions "  (Part  II,  p.  142).  |  See  "  Die  Lage  des  Foetus,"  Brauue,  Tab.  C. 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER. 


827 


ally  associated  with  uterine  dislocations,  and  are  familiar  to  those 
who  have  given  attention  to  gynecology.  There  remains  to  be  no- 
ticed two  forms  of  displacement  of  the  uterus  not  generally  described 
by  authors,  but  which  markedly  disturb  the  functions  of  the  blad- 
der, viz.,  7'etrocession  2iTi^  forward  transjposition.  In  the  first  form, 
the  uterus,  without  any  change  in  the  relation  of  its  axis  to  the 
plane  of  the  sujDerior  pelvic  strait,  is  found  to  rest  far  back  in  the 
pelvis,  and  is  fixed  there.  In  the  second  form,  the  reverse  of  this 
exists,  the  uterus  resting  just  behind  the  pubes.  Figs.  271  and  272, 
wiU  show  these  conditions. 

The  best  example  of  retrocession  I  have  ever  seen  was  in  a  pa- 
tient who  had  had  a  severe  pelvic  peritonitis  sometime  before  she  came 
to  me.  The  uterus  was  firmly  fixed  in  the  posterior  portion  of  the 
pelvis,  and  the  bladder  was  drawn  backward,  and  was  exceedingly 
irritable.     This  condition  caused  her  great  trouble,  as  she  could  never 


Fig.  269. — Forward  transposition  of  the  uterus.     The  bladder  will  be  seen  somewhat  flat- 
tened against  the  pubes,  and  the  urethra  pushed  out  of  its  axis. 


completely  empty  the  organ,  except  when  the  catheter  was  usedo 
Owing  to  the  fixation  of  these  organs  in  their  malposition,  it  was 
impossible  to  relieve  her  from  the  frequent  and  diflicult  urination, 
and  she  remained  a  great  sufferer,  until  she  died  of  phthisis  pul- 
monalis. 


828  DISEASES   OF  WOMEN. 

To  illustrate  the  forward  transposition,  I  may  mention  a  case 
that  came  under  xnj  notice  several  years  after  she  had  had  an  intra- 
peritoneal pelvic  hsematocele.     Her  physician  told  me  that  she  had 


Fig.  270. — Retrocession  of  the  uterus.     The  vagina  is  here  found  lengthened,  and  the 
bladder  and  urethra  pulled  upward  and  backward,     a,  adhesions,  b,  bladder. 

severe  inflammation  following  the  internal  haemorrhage,  and  nearly 
lost  her  life  therefrom.  She  was  confined  to  her  bed  for  many 
months,  and  after  recovery  she  suffered  from  frequent  urination. 
Night  and  day  she  was  obliged  to  pass  water  every  two  hours,  and 
if  she  went  longer  than  that,  she  had  pain  which  was  not  relieved 
till  some  time  after  emptying  the  bladder.  The  uterus  was  situated 
at  its  proper  elevation,  and  was  just  behind  the  pubes.  The  bladder 
was  compressed  from  before  backward,  and  (as  the  uterus  was 
firmly  fixed  in  its  forward  position)  of  course  it  could  never  be 
fully  distended.  There  was  no  disease  of  the  bladder,  so  far  as  could 
be  ascertained  from  an  examination  of  the  urine,  or  of  the  organ 
itself.  No  treatment  that  was  employed  gave  anything  more  than 
temporary  relief. 

(/)  Inversion  of  the  Bladder. — This  affection  stands  next  in  rarity 
of  occurrence  to  complete  prolapsus  of  the  bladder  through  a  fissure 
in  the  abdominal  walls.  It  is  sometimes  denominated  as  extrover- 
sion of  the  bladder  through  the  urethra. 


NON-INFLAMMATOKY   DISEASES   OF   THE   BLADDER.       829 

By  some  authors  it  is  supposed  to  be  a  simple  protrusion  of  the 
mucous  coat  of  the  bladder  through  the  urethra,  but  by  others  to  be 
a  prolapse  of  the  whole  organ.  In  support  of  the  latter  belief  is  the 
fact  that  after  death  Joubert,  Rurly  and  Leoret  found  a  sinking  in 
or  partial  inversion  of  the  whole  organ.  Moreover,  Meckel  claims  to 
have  found  under  the  labia  minora,  and  protruding  from  the  meatus 
a  mass  of  tissue  that  on  careful  examination  proved  to  consist  of  all 
the  elements  of  the  several  coats  of  the  bladder. 

Burns  thinks  it  much  easier  for  a  prolapse  of  the  whole  organ  to 
take  place  than  a  separation  and  prolapse  of  the  mucous  membrane 
alone.  Streubel,  after  a  careful  review  of  the  literature  of  the  sub- 
ject, was  able  to  find  but  one  case  in  which  the  mucous  membrane 
was  alone  prolapsed.  As  the  posterior  vesical  wall  in  the  empty 
organ  lies  over  the  vesical  opening  of  the  urethra,  it  is  easy  to  com- 
prehend how  this  dislocation  might  occur  from  sudden  straining 
efforts,  pressure  of  the  overloaded  colon,  or  pressure  of  a  heavy 
uterus.  Vesical  tumors  with  long  pedicles  coming  out  through  the 
urethra,  by  weight  or  from  traction,  might  produce  this  result. 
The  process  of  extroversion  is  generally  slow.  De  Haen,  quoted  by 
Streubel,  gives  a  case,  however,  where  from  force,  the  bladder,  rec- 
tum, and  vagina  were  all  prolapsed  together.  It  will  be  understood 
that  in  order  to  have  the  bladder  turned  inside  out,  the  urethra  must 
be  abnormally  dilated. 

It  may  occur  at  any  age.  Weinlecher  saw  it  in  a  child  but  nine 
months  old ;  Oliver,  in  one  of  sixteen  months ;  Crobs,  in  one  from 
two  to  three  years  ;  Streubel,  in  a  girl  fourteen  years  old ;  and  Thom- 
son and  Percy,  in  women  aged  respectively  forty  and  fifty -two. 

Symptomatology. — The  patients,  even  before  the  tumor  appears, 
feel  strong  pressure  in  the  organ  on  urination,  and  may  have  stop- 
pages in  the  stream  and  retention.  After  a  time  these  symptoms 
become  aggravated,  a  small  red  tumor  appears  at  the  meatus,  and 
with  each  urination  enlarges.  With  the  appearance  of  the  tumor 
comes  pain.  In  some  cases,  when  the  desire  to  urinate  is  felt,  severe 
contraction  of  the  bladder  takes  place,  but  no  urine  flows.  Then 
suddenly  the  little  tumor  disappears  inside,  and  the  urine  flows  freely. 
With  each  appearance  of  the  tumor  there  is  considerable  constitu- 
tional disturbance,  and  after  a  time  the  appetite  is  lost,  and  the  suf- 
ferers emaciate  rapidly.  From  continual  traction  on  the  ureters, 
they  may  become  inflamed,  and  also  the  kidneys,  and  ursemia  super- 
vene. Blood  is  sometimes  passed  with  the  urine.  Cystitis  may 
occur,  which  increases  the  suffering  and  danger.  The  mucous  mem- 
brane may  become  hypertrophied,  congested,  and  even  oedematous. 


830  DISEASES   OF  WOMEN. 

The  constitutional  symptoms  bear  no  relation  to  the  amount  of  tissue 
extruded  or  the  area  of  mucous  surface  exposed. 

Diagnosis. — Fortunately,  this  affection  is  a  rare  one,  for  the  diag- 
nosis is  by  no  means  easy.  The  surface  of  the  tumor  should  be  ex- 
amined, and  the  nature  of  its  epithelium  carefully  noted.  Reduc- 
tion should  be  tried,  and,  if  successful,  examination  should  be  made 
by  the  sound  in  the  bladder,  and  the  linger  in  vagina  or  rectum  (the 
latter  in  infants),  to  ascertain,  if  possible,  whether  there  be  any  thick- 
ening of  the  membrane  or  a  tumor  in  the  viscus.  If  on  the  surface 
of  the  protrusion  the  orilices  of  the  ureters  can  be  found,  the  diag- 
nosis is  at  once  settled.  Polypoid  projections  of  the  mucous  mem- 
brane must  be  differentiated  from  protrusion  of  the  viscus  itself. 
Such  cases  are  described  by  Baillie  and  Patron. 

From  prolapsus  of  the  urethral  mucous  membrane,  which  I  shall 
hereafter  describe,  this  condition  is  to  be  difl'erentiated  by  the  absence 
in  the  latter  of  the  ureteric  openings  and  the  position  of  the  meatus 
urinarius.  In  urethral  prolapse  the  orifice  is  situated  either  centrally 
or  superiorly,  while  in  vesical  protrusion  the  meatus  surrounds  the 
pedicle.  In  the  latter  there  is  a  large  strong  pedicle ;  in  the  fonner 
none. 

Treatment. — The  treatment  naturally  divides  itself  into  prophy- 
lactic and  curative.  To  prevent  partial  extroversion  from  becoming 
complete,  narcotics  and  demulcents  should  be  given  by  the  mouth 
and  rectum,  or  injected  into  the  bladder.  Opium,  hyoscyamus,  and 
belladonna  may  all  be  tried.  Local  cauterization  and  washing  out 
with  tonic  injections  might  prove  serviceable.  These  preventive 
means  are  usually  sufficient,  provided  the  urine  is  normal  and  the 
mucous  membrane  healthy.  If  either  of  these  abnormalities  exist, 
they  should  be  corrected. 

If  the  tumor  is  down,  its  reposition  should  be  attempted.  Gentle 
manipulation  with  the  finger  should  be  tried,  and,  if  the  mass  can 
not  be  put  back  in  this  way,  a  well-oiled  blunt  catheter  should  be 
used,  making  pressure  with  it  in  the  direction  of  the  axis  of  the 
urethra.  If  this  is  very  painful,  and  there  are  spasmodic  contrac- 
tions of  the  abdominal  muscles,  which  prevent  replacement,  the 
patient  should  be  etherized,  and  success  may  then  follow.  She  should 
be  on  her  back,  or  in  the  Sims's  position. 

To  prevent  prolapse  after  reduction,  the  catheter  may  remain  in 
situ  for  a  time,  or  the  colpeurynter  or  tampon  may  be  used.  Schatz's 
pessary  for  urinary  incontinence  may  be  employed  advantageously, 
as  its  use  tends  to  contract  the  vesical  neck.  Astringent  injections 
may  be  used.     No  operative  procedure  is  required. 


CHAPTER  XLY. 

NON-INFLAMMATORT   DISEASES    OF   THE   BLADDER    (cONTINUEd), 
FOREIGN  BODIES  IN   THE   BLADDER. 

Foeeign  bodies  found  in  the  female  bladder  are  divided  into  three 
classes  by  Winckel,  as  follows  : 

{a)  Those  that  come  from  the  body,  entering  the  bladder  by  per- 
foration. 

(Ij)  Those  which  have  their  origin  in  the  bladder. 

{c)  Those  that  are  introduced  from  without  through  the  urethra. 
I  will  adopt  this  classification,  believing  it  to  be  the  most  natural 
and  convenient. 

(a)  First  then,  as  to  those  that  come  from  the  body,  entering  the 
bladder  by  perforation. 

That  cysts  ever  originate  in  the  bladder  is  doubted  by  some  and 
denied  by  others.  In  most  cases  where  they  are  found  in  this  organ 
they  can  be  traced  to  dermoid  cysts  of  the  ovary  which  have  found 
their  way  into  it,  thus  accounting  for  the  presence  of  hair,  teeth,  and 
other  tissues  in  this  viscus.  These  things  are  never  found  there 
unless  such  a  cyst  has  opened  into  the  bladder.  The  contents  of 
these  dermoid  cysts  may  become  nuclei  for  calculi,  and  lead  to  seri- 
ous trouble. 

I  think  there  can  be  no  doubt  but  that  some  of  the  cysts  found 
in  the  bladder  have  their  origin  there.  Mucous  follicles  certainly 
do  exist  in  the  bladder,  and  are  liable  to  have  their  orifices  blocked 
or  occluded,  and  by  secretion  behind  the  point  of  obstruction  grad 
ually  form  cysts.  Interesting  cases,  where  the  cysts  evidently  had 
their  origin  in  the  bladder  itself,  are  related  by  Paget,  Liston,  and 
Campa.  It  is,  however,  undoubtedly  the  fact  that  most  cysts  of  the 
bladder  have  their  origin  outside  that  organ. 

Cysts  of  the  ureters  and  uraclius  may  open  into  the  bladder. 
Hydatid  cysts  have  been  found,  but  are  less  frequently  seen  in  this 

831 


832  DISEASES  OF  WOMEN. 

country  than  in  almost  any  other.  Iceland  is  especially  cursed  with 
them,  about  one  sixth  of  the  population  suffering  from  them  in  some 
part  of  the  body.  They  may  appear  in  the  urine,  white  and  pearly 
in  appearance,  or  be  of  a  dirty  yellowish  color,  from  prolonged  soak- 
ing in  foul  urine. 

Treatment. — These  cysts,  or  their  contents,  if  giving  rise  to  any 
trouble,  should  be  treated  in  the  same  manner  as  the  neoplasms,  of 
which  I  shall  speak  later. 

In  the  treatment  of  hydatid  cysts,  iodide  of  potassium  has  been 
especially  recommended.  Having  never  had  occasion  to  use  it  for 
this  purpose,  I  can  say  very  little  for  or  against  it. 

Other  Foreign  Bodies. — Various  parts  of  the  foetus  have  found 
their  way  into  the  bladder  by  ulceration  during  extra-uterine  preg- 
nancy, and  pieces  of  ulcerated  intestine,  masses  of  feces,  fecal  con- 
cretions, and  biliary  concretions,  are  some  of  the  curious  things  that 
have  been  found  in  this  viscus.  In  gun-shot  and  other  injuries  to 
the  pelvic  bones,  osseous  splinters  have  found  their  way  into  the 
viscus,  and  been  evacuated  through  the  urethra,  or  have  passed  into 
the  vagina  or  rectum  by  ulceration,  or  have  remained,  forming  nuclei 
for  calculi. 

Yarious  parasites  may  penetrate  the  walls  from  the  immediate 
tissue  or  neighboring  organs,  or  come  down  from  the  kidneys,  such 
as  the  echinococci,  already  spoken  of,  the  distoma  haematobium  or 
the  iilaria  sanguinis  hominis.  Joints  of  tape-worm,  the  ascaris  lum- 
bricoides,  and  the  thread-  or  seat-worms  have  also  been  found  here, 
entering  either  through  a  fistulous  opening,  existing  between  the 
bladder  and  intestine,  or  through  the  urethra. 

In  acute  destructive  change  in  the  kidneys  (pyonephrosis  and 
abscess),  pus  and  pieces  of  renal  tissue  are  not  unfrequently  carried 
down  into  the  bladder,  and  may,  by  frequent  incrustation  with 
the  urinary  salts,  result  in  the  formation  of  calculi.  Of  themselves, 
they  give  rise  to  very  little,  if  any,  irritation,  and  are  consequently 
of  no  importance  save  in  relation  to  the  destructive  changes  going 
on  in  the  kidney,  of  which  they  tell  the  story.  If  such  discharges 
from  the  kidneys  continue  for  a  long  time,  they  cause  cystitis. 

Kenal  calculi  may  become  dislodged,  and  be  swept  down  into  the 
bladder,  there  to  enlarge  by  further  incrustations,  or  pass  out  through 
the  urethra. 

I^yinptoinatology. — The  symptoms  of  the  various  foreign  bodies 
in  the  bladder  differ  only  in  degree.  They  are  at  first  those  of  irri- 
tation ;  later  those  of  acute  or  subacute  inflammation.  Bodies  round, 
smooth,  and  soft,  are,  of  course,  less  irritant  than  those  that  are  rough 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER,       833 

or  sharp.  Cysts,  therefore,  bits  of  flesh,  aud  tlieir  like,  as  a  rule, 
give  ris6  to  no  very  severe  symptoms,  while  splinters  of  bone  and 
calculi  occasion  much  more  severe  manifestations.  Pain  and  tenes- 
mus will  vary  with  the  character  of  the  offending  body.  If  the 
mucous  surface  be  abraded  or  torn,  hsematuria  will  result ;  and,  if 
the  foreign  body  remains  in  the  organ,  and  continues  to  irritate  it, 
cystitis  will  follow,  and  the  patient  suffer  increased  agony. 

The  extension  of  the  inflanmiation  upward,  and  involvement  of 
one  or  both  kidneys,  will  give  rise  to  pain  in  the  back,  hectic  fever, 
partial  or  total  suppression  of  urine,  and  consequent  uraemic  symp- 
toms, ending  fatally. 

The  urine  shows  the  various  appearances  of  cystitis,  of  which 
suflicient  has  already  been  said,  and  also  the  signs  of  renal  involve- 
ment, if  such  be  present. 

Treatment. — Any  foreign  body,  when  known  to  be  present  in 
the  bladder,  should  be  removed  at  as  early  a  date  as  possible.  In 
the  adult  female  this  may  be  readily  accomplished  by  dilatation  of 
the  urethra,  or,  if  the  body  be  too  large,  by  Simon's  vesico-vaginal 
section. 

In  cases  of  fistulous  communication  between  the  bladder  and  in- 
testine or  other  organ,  an  attempt  should  be  made,  in  the  manner 
already  spoken  of,  to  close  the  opening. 

Echinococci  and  other  parasites  should  be  treated  with  the  vari- 
ous remedies  recommended  for  their  destruction  elsewhere,  always, 
however,  removing  the  offending  body  from  the  bladder  first,  and 
trying  to  prevent  further  invasion  by  proper  medication. 

If  cystitis  be  present,  this  will  be  attended  to  in  the  prescribed 
way. 

Hydatids  in  the  Bladder. — Dr.  J.  A.  McKennion,  of  Selma,  Ala- 
bama, reported  a  case  in  the  "  American  Medical  AVeekly,"  Louisville, 
Kentucky,  in  1874  or  18Y5.  The  purport  of  this  report,  according 
to  my  recollection,  is  that  it  was  a  case  which,  when  first  seen,  had 
every  indication  of  cystitis,  with  great  thickening  of  the  walls  of  the 
bladder.  Frequent  micturition  caused  the  patient  to  exclude  her- 
self from  society  for  two  years  before  a  correct  diagnosis  of  the  case 
was  formed.  She  was  becoming  pi'ostrated  from  constant  dysuria, 
and,  in  order  to  give  her  quietude,  Dr.  McKennion  says,  I  attemjDted 
to  introduce  a  Sims's  catheter,  to  be  retained  during  the  night ;  but, 
meeting  with  an  obstruction  in  the  bladder,  and,  by  manipulation 
with  catheter,  finding  that  she  was  insensible  as  to  the  point  of  the 
instrument,  I  concluded  that  a  hydatid  formation  was  present,  and 
designed  at  once  to  have  it  expelled  if  possible. 
54 


83i  DISEASES  OF  WOMEK 

I  would  say  here  one  of  the  strongest  arguments  in  my  own  mind 
at  the  time  of  hydatid  formation  was,  when  force  was  used  to  pusli 
up  the  instrument  farther,  a  small  amount  of  fluid  escaped,  and  no 
blood.  I  injected  into  the  bladder  two  drachms  of  liq.  sodse  chlor. 
(French  preparation).  In  about  an  hour  violent  spasms  of  the  blad- 
der occurred,  the  urethra  dilated,  and  there  was  expelled  into  the 
vessel  about  a  pint  of  hydatid.  The  shape  and  attachment  of  these 
resembled  the  cactus ;  the  sacs  were  transparent  and  well  defined. 
There  was  but  slight  haemorrhage.  This  I  attributed  to  the  forcible 
distention  of  the  urethra.  It  is  now  over  five  years  since  their  ex- 
pulsion, and  up  to  this  day  my  patient  has  had  no  more  inconven- 
ience with  her  bladder.  Fortunately,  my  case  was  a  female,  and 
she  is  well ;  this  might  not  have  been  if  it  had  been  one  of  our  own 
sex. — Ne  1.1:1  Yo7'k  Medical  Record^  Nfrvemher  20,  1880,  p.  588. 

(b)  Bodies  having  their  Origin  in  the  Bladder  Itself. — Under  this 
head  come  calculi,  which  may  be  of  various  kinds,  as  uric  acid,  triple 
and  amorphous  phosphates,  oxalate  of  lime,  and  cystine.  The  latter 
are  quite  rare.  Again,  the  calculi  may  consist  of  more  than  one  of 
these  ingredients. 

Time  will  not  allow  me  to  enter  into  the  extensive  field  embrac- 
ing the  etiology  and  treatment  of  stone.  For  a  comprehensive  study 
of  this  matter,  I  must  refer  the  reader  to  any  one  of  the  many  excel- 
lent works  on  that  subject. 

Calculus. — I  shall  only  speak  of  one  or  two  points  in  connection 
with  calculus  that  are  of  especial  interest  in  the  study  of  disease  of 
the  female  bladder.  Stone  in  the  bladder  is  not  so  common  among 
women  as  among  men.  This,  I  presume,  is  owing  to  the  large  and 
easily  dilatable  urethra  of  the  female,  which  permits  small  renal  cal- 
culi to  pass  out ;  calculi  of  the  same  size  in  the  male  being  retained 
in  the  bladder,  and  serving  as  nuclei  for  larger  ones. 

Si/mpto9nat(do(/f/. — The  symptoms  are  simply  those  of  a  foreign 
body  in  the  bladder,  varying  with  the  size,  shape,  and  number  of 
the  stones,  and  also  their  roughness  of  surface.  Frequent  urina- 
tions, tenesmus,  pain  before,  during,  and  after  urination,  some- 
times incontinence,  and  always  more  or  less  cystitis.  Hjematuria  is 
not  at  all  infrequent,  and  the  urine  presents  all  the  characters  of 
bladder  inflammation,  as  shown  by  the  presence  of  pus,  epithelium, 
and,  sooner,  or  later,  numerous  crystals  of  the  triple  and  amorphous 
phosphates. 

The  constitution  suffers  from  the  constant  pain  and  frequent 
urination,  and  the  patient  gives  all  the  symptoms  of  a  severe  cystitis. 

Diagnosis. — This  is  comparatively  easy  in  the  female  bladder. 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       835 

for  between  the  judicious  use  of  the  sound,  conjoined  manipulation, 
and  the  bladder  speculum,  a  stone  can  hardly  escape  detection  un- 
less it  be  very  small  or  completely  encysted. 

Prognosis. — The  prognosis  in  vesical  calculus  in  women  is  good, 
provided  the  kidneys  be  not  seriously  disordered.  The  cystitis  usu- 
ally disappears  soon  after  removal  of  the  foreign  body,  under 
proper  treatment ;  and  even  if  renal  disease  exist,  it  may  also  sub- 
side. 

Causation. — The  causes  of  stone  in  the  bladder  are  about  the 
same  in  both  sexes,  and  so  I  need  not  dwell  long  on  this  part  of  the 
subject.  I  may  call  attention  to  one  cause  of  the  formation  of 
stone  in  the  bladder  of  the  female.  In  cystocele,  a  mass  of  mucus 
or  shreds  of  membrane  and  triple  and  amorphous  phosphates  gradu- 
ally collect  in  this  abnormal  pouch,  and  form  a  nucleus  for  stone. 
It  is  a  curious  fact,  too,  that  women  are  particularly  liable  to  have 
stone  after  the  operation  for  closure  of  vesico-vaginal  fistula.  There 
has  been  considerable  discussion  as  to  whether  calculi,  discovered 
soon  after  this  operation,  existed  undiscovered  in  the  bladder  before 
the  operation,  or  were  formed  rapidly  after  it.  Henry  F.  Camp- 
bell, M.  D.,  of  Virginia,  relates  one  case  in  favor  of  the  former 
view,  and  Dr.  T.  A.  Emmet  several  in  favor  of  the  latter. 

The  belief  has  been  advanced  that  irritation  in  the  bladder  mod- 
ifies the  urinary  secretion  sufficiently  to  cause  deposit  of  the  urin- 
ary salts,  and  thus  account  for  the  formation  of  stone  after  the 
operation  for  fistula.  It  is  claimed  that  reflex  nerve  action  is  ex- 
cited by  the  operation,  the  inflammatory  action  about  the  edges  of 
the  wound,  or  by  cystitis  already  existing. 

This  idea  that  the  reflex  nerve  influence  modifies  the  urinary  se- 
cretion sufiiciently  to  result  in  the  formation  of  stone  in  these  cases, 
is,  I  think,  hardly  tenable ;  for  in  hundreds  of  cases  of  cystitis, 
where  the  reflex  action  does  undoubtedly^  exist,  no  stone  is  formed. 
Then,  too,  the  secretion  is  as  a  rule  rendered  more  watery,  instead 
of  concentrated,  a  condition  in  which  precipitation  of  the  urinary- 
salts  would  be  very  unlikely  to  take  place. 

A  middle  position  on  this  question  seems  to  me  to  be  the  most 
rational,  and  stones  found  after  operations  for  closing  fistula  might 
be  due  to  any  one  of  three  causes  : 

{a)  Calculus  already  existing  in  the  bladder,  escaping  detection  by 
being  pocketed,  or  so  small  as  to  lie  beneath  a  mucous  fold,  and 
rapidly  increasing  in  size  after  operation,  due  to  the  retention  of  the 
salts  of  the  urine  (deposited  by  decomposition),  that  formerly  es- 
caped by  means  of  the  fistula. 


836  DISEASES   OF  WOMEN. 

(5)  Calculi,  small  or  large,  existing  in  the  kidneys  or  renal  pelves, 
and  washed  down  after  the  operation  by  the  increased  flow  of  limpid 
urine :  these,  too,  increasing  in  size  by  incrustation. 

{c)  Calculi,  the  formation  of  which  commences  directly  after 
closure  of  the  wound,  due  partly  to  retained  products  of  decomposi- 
tion, possibly  to  modified  secretion,  or  to  small  nuclei  swept  down 
from  the  kidney,  or,  what  is  much  more  likely,  to  nuclei  consisting 
of  pieces  of  mucous  shreds,  blood-clots,  or  possibly  incrustations  on 
one  or  more  of  the  sutures  which  may  be  exposed  in  the  bladder. 

I  am  quite  sure  that  the  formation  of  calculi  after  closing  a  ves- 
ico-vaginal  fistula  is  favored  by  the  presence  of  the  catheter  in  the 
bladder  during  the  healing  process.  The  drainage  is  imperfect  and 
if  the  bladder  is  not  frequently  washed  there  is  every  facility  for  the 
deposit  of  urinary  salts  and  the  formation  of  stone.  I  am  the  more 
persuaded  that  this  explanation  is  correct  from  the  fact  that,  since  I 
have  permitted  my  patients  to  empty  the  bladder  in  the  natural  way 
after  the  operation,  I  have  not  had  a  case  of  stone  following  this 
operation. 

Treatment. — The  female  bladder  presents  an  inviting  field  for 
experiments  on  the  treatment  of  stone  by  solvents  ;  but  as  the  opera- 
tion here  is  so  easy  and  its  results  so  good,  it  seems  hardly  justifiable 
to  recommend  any  other  method  of  treatment.  In  patients,  how- 
ever, who  object  to  the  operation,  it  may  be  tried.  For  a  full  and 
interesting  account  of  experiments  and  statistics  on  the  solvent 
method,  I  refer  to  Mr.  Roberts's  most  excellent  work  on  "  Urinary 
and  Renal  Diseases." 

The  stone  being  found  and  its  size  determined,  it  may  either  be 
removed  by  cystotomy  or  crushed.  If  the  stone  be  small  and  soft, 
it  may  be  advisable  to  crush  it,  washing  out  the  fragments  through 
the  open  speculum  in  the  moderately  dilated  urethra,  thus  saving 
the  urethral  mucous  membrane  from  laceration  by  the  sharp  fi'ag- 
ments ;  or  better  still  the  dehris  may  be  removed  by  Bigelow's 
method. 

If  much  cystitis  be  present,  however,  or  if  the  stone  be  large,  it 
is  advisable  to  perform  vaginal  cystotomy.  In  this  way  a  stone  of 
large  size  may  be  removed  from  any  part  of  the  bladder,  and  an 
opening  for  drainage  is  left  to  act  beneficially  on  the  inflamed  organ 
by  giving  vent  to  the  urine  and  its  sediment.  The  bladder  should 
be  carefully  washed  out  daily  with  a  warm  solution  of  salicylic  acid 
(1  to  600  or  1  to  400j.  If  drainage  is  desired,  care  must  be  taken  to 
keep  the  incision  open,  for  it  closes  veiy  readily. 

I  have  spoken  several  times  already  as  to  the  method  of  per- 


NOX-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       837 

foraimg  vaginal  cystotomy,  Emmet  dwells  especially  and  justly  on 
the  necessity  of  Mxing  the  vesico-vaginal  wall  Hrmly  with  a  tenacu- 
him  before  commencing  the  incision,  which  may  be  made  with 
either  a  knife  or  scissors.  A  calculus  in  the  bladder,  if  interfering 
with  labor,  or  if  liable  to  be  caught  between  the  child's  head  and 
the  pubes,  should,  if  possible,  be  pushed  up  out  of  the  way.  This  is 
seldom  successful,  and  as  much  damage  may  be  done  the  bladder  by 
the  crushing  of  its  walls,  it  is  best  to  puncture  and  remove  the  stone 
at  once  in  ease  there  is  time  during  the  labor  and  the  attendant  is 
prepared  to  operate.  Should  it  be  impossible  to  operate  before 
labor  is  completed,  it  should  be  done  as  soon  afterward  as  practi- 
cable. It  should  be  borne  in  mind  that  the  vascularity  is  greater  in 
the  puerperal  state  and  hence  every  preparation  should  be  made  to 
arrest  hajmorrhage. 

ILLUSTKATR''E   CASES. 

Foreign  Bodies  in  the  Bladder. — ^By  L.  H.  Dunning,  M.  D. ;  read 

before  the  "  Indiana  State  Medical  Society  "  : 

Case  I. — Mrs.  A.,  aged  thirty-eight,  married,  a  lady  of  culture 
and  reiinement,  was  delivered,  four  years  previously,  of  a  hydro- 
cephaloid  child.  The  delivery  was  instrumental.  Whether  from 
long  pressure  of  an  abnormally  la,rge  head,  or  from  maladroit  use 
of  instruments,  I  know  not,  a  vesico-uterine  or  vaginal  fistula  re- 
sulted. The  precise  location  of  the  original  opening  of  the  vaginal 
or  uterine  extremity  of  the  fistula  I  am  unable  to  state,  as  two 
operations  had  been  done  for  its  closure,  both  of  which  were  un- 
successful. The  last  operation  was  done  in  June,  1883,  and  in 
the  folloAving  December  I  was  consulted  in  consequence  of  intense 
pain  and  burning  in  the  region  of  the  bladder,  and  pain  at  the 
close  of  the  act  of  urinating.  The  patient  stated  she  had,  a  few 
weeks  previously,  passed  a  small  stone  by  the  urethra,  and  now 
thought  there  was  another  and  larger  one  present.  An  examination, 
with  the  sound  confirmed  her  diagnosis.  I  proceeded  to  remove 
the  stone,  assisted  by  Dr,  S,  L,  Kilmer.  The  urethra  was  dilated 
with  a  three-bladed  dilator,  the  stone  crushed  with  a  Thompson's 
lithotrite,  and  removed  with  Bigelow's  evacuating  apparatus.  We 
were  both  confident  all  the  stone  was  removed.  The  patient  made 
a  good  recovery,  but  was  not  entirely  relieved  of  the  bladder  symp- 
toms. In  March,  18S4,  I  was  again  called  to  remove  a  stone,  which 
the  patient  stated  she  had  felt  with  the  large  end  of  a  shawl-pin  in- 
troduced into  the  bladder  through  the  urethra.  This  time,  assisted 
by  Dr,  M,  L.  Morse,  a  large  quantity  of  stone  was  removed  in  the 
same  manner  as  at  the  first  operation.    The  lithotrite  was  introduced 


838  DISEASES   OF  WOMEN". 

three  times,  and,  the  last  time  it  was  withdrawn,  we  found  within 
the  grasp  of  its  closed  blades  a  silver-wire  suture,  with  the  loop  cut, 
but  the  twist  intact.  The  whole  was  coated  with  a  phosphate-of-lime 
deposit.  We  now  felt  confident  we  had  secured  the  foreign  body 
around  which  the  calculus  had  collected.  The  patient  stated  to  us 
that  she  had  been  aware  ever  since  the  last  operation  for  fistula  that 
there  was  a  wire  left  behind,  and  that  she  had  once  visited  the  sur- 
geon to  have  it  removed,  but  it  could  not  be  found.  There  are 
many  other  points  of  exceeding  interest  connected  with  this  case, 
but  they  are  not  pertinent  to  this  subject,  hence  will  be  omitted. 
There  was  a  band  of  dense  cicatricial  tissue  extending  transversely 
across  the  fundus  of  the  bladder.  Posterior  to  this  band  was  a 
pocket,  in  the  bottom  of  which  was  the  vesical  extremity  of  the  fist- 
ula. In  this  pocket  lodged  the  stone,  and  was  evidently  made  sta- 
tionary by  the  suture,  which  remained  partly  imbedded  in  the  tissues. 
That  the  wire  rendered  the  stone  stationary  finds  support  in  the  fact 
that,  July  18th,  four  months  after  the  wire  was  removed,  a  fourth 
large  calculus  had  formed  in  the  bladder,  and  was  quite  movable. 
This  last  calculus  was  readily  crushed,  and  voluntarily  expelled  from 
the  bladder  along  with  water  freely  injected  into  the  organ.  Since 
this  fourth  stone  was  removed,  there  have  been  no  signs  or  symp- 
toms of  a  calculus  in  the  bladder. 

Case  IT. — Mr.  B.,  a  laborer,  aged  fifty-seven  years,  was  brought 
to  me,  by  Dr.  Kettring,  September  19th,  of  last  year,  for  the  re- 
moval of  a  foreign  body  from  the  bladder.  The  patient  stated  that, 
about  the  middle  of  August,  he  passed  a  cigarette-holder  into  the 
orifice  of  the  urethra ;  that  it  slipped  away  from  him,  and  passed 
down  into  the  urethra,  and,  in  his  efforts  to  remove  it,  pushed  it 
into  the  bladder.  Being  a  mechanic,  he  had  invented  an  instrument 
with  which  he  attempted  to  remove  the  body,  without  success.  I 
sounded  the  bladder,  and  found  the  holder  lying  obliquely  across 
the  organ.  I  judged  it  to  be  about  two  and  one  half  inches  long, 
and  as  thick  as  a  small  lead-pencil.  A  No.  1 8^  sound  dropped  readily 
into  the  bladder,  and,  since  the  urethra  was  of  so  large  a  caliber,  and 
the  patient  had  frequently  passed  his  instrument  along  its  track,  I 
concluded  to  attempt  its  remov^al  without  further  dilatation.  A 
Thompson's  lithotrite  was  introduced,  and  the  body  seized ;  but  I 
was  made  conscious  that  the  instrument  did  not  grasp  it  at  the  end, 
so  I  withdrew  the  lithotrite  and  introduced  a  sound,  and  endeavored 
to  bring  the  long  diameter  of  the  holder  in  line  with  the  urethra. 
Now,  with  but  little  difiiculty,  the  end  was  grasped  by  the  blades 
of  the  lithotrite,  and  I  proceeded  to  withdraw  the  whole.     It  soon 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.        839 

became  evident  that  we  had  not  rightly  estimated  the  size  of  the 
holder,  for,  although  it,  together  with  the  instrument,  entered  the 
prostatic  portion  of  the  urethra,  we  had  consideraljle  dithculty  in 
making  it  advance  through  the  membranous  portion.  However, 
avoiding  much  force,  but  keeping  steadily  at  work,  with  the  aid  of 
Dr.  Kettring,  I  succeeded  in  withdrawing  it  to  within  one  inch  and 
a  half  of  the  orifice  of  the  urethra.  Further  than  this  we  could 
not  advance ;  so  the  urethra  was  incised  posteriorly  down  to  the  end 
of  the  holder,  and,  by  applying  pressure  from  behind,  made  to  enter 
the  incision,  and  was  finally  entirely  withdrawn.  We  were  surprised 
to  see  the  size  of  the  holder  and  its  breadth  when  in  the  grasp  of  the 
lithotrite,  thirty-five  millimetres.  There  was  a  moderate  amount  of 
haemorrhage  from  the  urethra  or  bladder ;  probably  from  the  mem- 
hranous  portion  of  the  urethra,  since  that  is  the  most  constricted  por- 
tion of  the  canal.  The  bladder  was  washed  out  with  tepid  water, 
and  the  patient  taken  to  his  home  in  a  closed  carriage,  the  operation 
having  been  done  at  my  ofiice  on  account  of  the  patient's  refusing  to 
have  it  done  at  home  for  fear  of  exposure.  Soon  after  reaching 
home,  the  patient  had  a  chill,  followed  by  fever.  In  the  next 
twenty-four  hours  he  had  three  chills,  each  time  followed  by  in- 
creased fever,  the  temperature  ranging  from  102°  to  104°  F.  The 
urine  passed  was  freely  mixed  with  a  considerable  quantity  of  mucus 
and  a  little  blood. 

20th,  1.30  p.  M. — Patient  seen  by  Dr.  Kettring  and  myself.  Had 
a  temperature  of  106°.  He  voided  urine  in  our  presence ;  it  was 
quite  bloody,  and,  upon  close  examination,  was  found  to  contain  a 
wedge-shaped  piece  of  mucous  membrane  twelve  millimetres  long, 
four  millimetres  broad,  and  about  two  millimetres  thick.  This  was 
not  examined  with  the  glass,  but  was  supposed  to  be  from  the  mem- 
branous portion  of  the  urethra,  since  at  that  point  there  was  the  most 
resistance.  There  were  also  voided  at  this  time  several  small  grains 
of  gravel,  some  as  large  as  wheat-grains  Patient  complained  of  con- 
siderable pain.  Bladder  was  washed  out  with  warm  carbolized  water. 
Twenty  grains  of  quinia  sul.  were  given  ;  one  grain  opium  and  ten 
grains  of  acetate  of  potash  every  four  to  six  hours,  and  a  milk-diet 
ordered.  Further  than  this,  I  will  not  attempt  to  minutely  detail  the 
history  of  the  case,  but  will  simply  outline  it.  In  the  next  twenty- 
four  hours  the  patient  had  four  chills.  The  temperature  ranged  from 
101°  to  104:°,  and  the  pulse  from  108  to  120  per  minute.  Patient 
perspired  profusely,  and  was  at  times  delirious ;  great  nervousness ; 
prognosis  was  regarded  unfavorable.  Whisky,  in  3  jss  doses,  every 
hour,  when  the  temperature  mounted  high,  was  added  to  the  treat- 


840  DISEASES   OF   WOMEN. 

ment.  Dr.  Kettring  washed  out  the  bladder  twice  every  day,  using 
for  this  purpose  a  soft-rubber  catheter  and  a  rubber  bag.  We  de- 
bated the  advisability  of  this  procedure,  but  found  that,  by  this 
means,  we  removed  a  considerable  quantity  of  turbid  urine,  small 
clots  of  blood,  and  occasionally  small  grains  of  gravel ;  and  further, 
the  cleansing  of  the  bladder  seemed  to  afford  the  patient  relief ;  so 
we  decided  to  persist  in  it  as  long  as  its  use  was  indicated. 

22d. — Patient  slightly  delirious ;  pulse,  112  ;  temperature,  101°  ; 
slept  moderately  well  last  night :  has  had  no  chill  since  9  p.  m.  yes- 
terday. Dr.  Kettring  found  morphine,  gr.  one  sixth,  ar.  spts.  ammo., 
3  jss,  very  efficient  in  relieving  or  aborting  the  cbills.  At  noon 
to-day  patient  seemed  much  better ;  at  9  p.  m.  temperature  had  fallen 
to  100°,  and  pulse  to  90  ;  but  the  urine  had  accumulated  in  the  blad- 
der, and  had  to  be  removed  by  catheterization. 

23d,  7.30  A.  M. — Patient  rational ;  has  slept  well  during  the 
night,  and  voided  urine  frequently ;  pulse  is  70,  and  temperature 
normal ;  the  nervous  symptoms  have  nearly  disappeared  ;  had  symp- 
toms of  a  chill  last  night,  which  quickly  disappeared  under  the  effects 
of  the  morphine  and  ar.  spts.  of  ammo.,  with  the  addition  of  ten 
drops  of  chloroform. 

From  this  time  forward  the  recovery  was  uninterrupted.  In  one 
week  the  patient  was  able  to  sit  up.  A  few  days  later  he  was  walk- 
ing about  the  streets,  and  in  two  weeks  after  the  operation  resumed 
work. 

Thus  happily  terminated  a  case  that  at  one  time  was  exceedingly 
alarming,  in  consequence  of  the  intense  urethral  fever  that  devel- 
oped. It  would  undoubtedly  have  proved  fatal  had  it  not  been  for 
the  skill  and  unremitting  attention  bestowed  upon  the  case  by  Dr. 
Kettring. 

Stone  in  the  Bladder ;  Lithotrity  by  a  Single  Operation.  (N.  A. 
Powell,  M.  D.,  Edgar,  Ontario.) — S.  F.,  aged  now  live  years,  first 
presented  symptoms  of  trouble  referable  to  the  urinary  organs  in 
October,  1876.  Pain,  partial  incontinence,  and  the  passage  of 
blood  and  mucus  continued  from  this  time,  and  in  January,  1878,  a 
bit  of  "  gravel "  the  size  of  a  split  pea  came  away.  During  the 
following  spring  the  desire  for  urination  became  almost  constant, 
and  vesical  tenesmus  was  marked.  On  June  12th,  ray  friend,  Dr. 
I>lackstock,  of  Hillsdale,  was  called  to  see  her,  and  on  the  13th, 
under  an  anresthetic,  he  examined,  and  found  a  calculus  at  the  neck 
of  the  bladder. 

An  operation  for  its  removal  was  advised,  and  pending  this, 
anodynes  were  freely  given.     On  July  9th,  the  writer,  in  consulta- 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       841 

tion,  saw  the  case  for  the  lirst  and  only  time.  The  child  was  said 
to  be  faihng  very  fast ;  she  was  much  emaciated ;  was  suffering 
severely,  and  seemed  to  gain  a  respite  from  her  pain  only  when 
violently  rocked  while  in  the  knee-chest  position  in  a  cradle.  Pulse 
140,  temperature  102^°  F.  Chloroform,  replaced  later  by  ether,  was 
given,  and  a  stone  found  jammed  into  the  upper  part  of  the  urethra. 
This  was  displaced  upward,  caught  in  the  blades  of  a  smaller  Weiss 
and  Thompson  lithotrite,  and  crushed.  The  scale  showed  five  eighths 
of  an  inch  separation  of  the  blades.  Further  comminution  of  the 
fragments  was  effected  by  means  of  long  polypus  forceps.  Evacua- 
tion was  accomplished  by  the  same,  aided  by  the  frequent  injection 
and  aspiration  of  warm  water  through  a  large-sized  Eustachian 
catheter,  to  which  a  strong  rubber  bulb  had  been  attached.  This 
last  was  the  best  substitute  at  hand  for  Bigelow's  or  Clover's  appa- 
ratus. The  vagina  was  too  small  to  admit  a  finger  without  undue 
stretching,  but  water  could  be  retained  in  the  bladder  by  pressure 
upon  the  urethra. 

The  first  calculus  being  removed,  suprapubic  pressure  brought 
two  other  and  smaller  ones  within  reach,  and  these  were  treated  as 
the  first  had  been.  The  distance  between  the  outer  surfaces  of  the 
blades  of  the  forceps  used  when  grasping  the  largest  fragment  re- 
moved was  three  tenths  of  an  inch;  this,  then,  was  the  limit  of 
urethral  dilatation.  The  lithotrite  was  used  for  crushing  five  times, 
the  forceps  twenty  or  thirty  times.  The  time  occupied  was  one 
hour  and  a  quarter.  The  bladder  being  washed  and  aspirated  till, 
as  nearly  as  possible,  freed  of  its  solid  contents,  the  child  was  put  to 
bed  with  hot  applications  over  the  pubes  and  to  the  extremities,  and 
a  full  anodyne  was  given.  The  detritus  collected  at  the  time  of 
operation  weighed  241  grains;  subsequently  seven  grains  more 
were  obtained  from  the  strained  urine. 

For  the  history  of  the  case  after  this,  I  am  indebted  to  notes 
kindly  sent  me  by  Dr.  Blackstock  or  his  assistant  Mr.  Gould,  who, 
with  my  students  Messrs.  Shepherd  and  Bremmer,  gave  assistance 
during  the  operation.  "  Partial  control  of  the  urine  returned  on  the 
day  following  the  lithotrity,  and  complete  control,  except  during 
the  night,  after  three  days.  The  desire  to  void  urine  occurred 
about  every  hour  for  several  days,  and  at  the  end  of  a  week,  about 
every  third  hour.  Slight  hEematuria  was  noticed  for  two  days." 
Under  date  August  27th,  I  hear  that  "the  child's  general  health  is 
good.  She  is  gaining  in  flesh,  and  has  no  symptoms  of  her  former 
trouble." 

The  above  case  would  a  year  ago,  hardly  have  merited  transcrip- 


842  DISEASES   OF  WOMEN. 

tion  from  the  case-book  of  a  country  physician  to  the  pages  of  a 
medical  journal.  But  since  the  appearance  of  Dr.  Bigelow's  paper 
on  litholapaxy  *  the  whole  subject  of  the  tolerance  of  the  urinary 
bladder  for  prolonged  instrumentation  has  come  up  for  reconsid- 
eration, and  this  is  offered  in  evidence. 

From  Civiale  down,  all  lithotritists,  so  far  as  the  writer's  knowl- 
edge extends,  have  held  that  the  visits  of  a  lithotrite  to  the  interior 
of  a  bladder  must  be  strictly  limited  in  point  of  time.  Though  ex- 
perts may,  at  times,  have  given  themselves  more  latitude,  they  have 
always  taught  others  not  to  exceed  five  minutes  for  any  one  crush- 
ing. Of  late  years,  also,  the  tendency  has  been  to  confine  the  opera- 
tion within  narrow  and  yet  more  narrow  limits,  treating  by  it  only 
such  moderate  sized  stones  as  could  be  got  rid  of  in  from  two  to 
four  sittings.  It  remained  for  the  Harvard  professor  to  demonstrate 
that  the  calculus-containing  bladder  of  an  etherized  man  might  be 
manipulated  for  one,  two,  or  more  hours,  and  yet  not  resent  it  by 
cystitis  or  subsequent  atony  ;  ^wovided  that  no  sharp  fragments  were 
left  in  it  to  do  outrage  to  its  lining  membrane.  Although  the  case 
just  given  occurred  in  a  female  child  instead  of  in  an  adult  male,  it 
seems  to  support  Dr.  Bigelow's  conclusions  as  to  vesical  tolerance. 
Surely  the  delicate  tissue  of  a  child's  bladder  is  ill  adapted  for  pro- 
longed contact  with  instruments,  while  the  proportion  of  the  organ 
covered  by  periton[eum  in  the  child  being  greater  than  in  the  adult, 
there  would  seem  to  be  a  greater  danger  of  serous  inflammation. 
Yet,  here  all  irritation  j)romptly  subsided  when  the  irritant  was  re- 
moved, although  its  removal  took  one  hour  and  a  quarter.  May 
we  not  expect  like  results  when  even  large  stones  are  crushed  in  the 
male  bladder,  and  evacuated  by  the  new  method  %  Statistics  so  far 
— seventeen  cases,  sixteen  successful — seem  to  point  that  way. 

It  may  be  asked  why  the  urethra  was  not  more  widely  dilated 
in  this  case  %  My  answer  is  that  too  large  a  proportion  of  those  thus 
treated  have  been  made  dribblers  for  life  by  it.  The  ease  with 
which  stretching  may  be  accom])lished,  and  the  free  access  which  it 
gives  to  the  bladder,  will  strongly  tempt  a  surgeon  who  does  not 
look  beyond  the  operation  he  has  to  do  at  the  future  life  of  his 
patient.  Prof.  Simon,  of  Heidelberg,  made  f  many  accurate  meas- 
urements to  determine  the  extent  to  which  the  adult  female  Urethra 
may  be  dilated  without  the  risk  of  incontinence.  His  limit  is  in 
width,  eight  tenths  of  an  inch ;  in  circumference,  6'3  cen.,  (=2-4 
inches).     This  would  allow  a  finger  to  pass,  but  not  a  finger  plus  a 

*  "  American  Journal  of  Medical  Sciences,"  January,  1878. 
f  Translation  in  "  New  York  Mcilical  Journal,"  October,  1875. 


NON-INFLAMMATORY  biSEASES   OF  THE  BLADDER.       843 

pair  of  forceps.  Mr.  J.  R.  Lane  thinks  no  stone  larger  than  an 
acorn  should  be  removed  entire  through  the  urethra  of  an  adult 
female,  and  none  larger  than  a  beau  through  that  of  a  child.  Dr. 
Hunter  McGuire,  of  Richmond,  Va.,  states  that  many  cases  of  so- 
called  successful  operations  by  dilatation  and  extraction  have,  to  his 
personal  knowledge,  been  followed  by  incontinence.  Rapid  dilata- 
tion, however,  seems  to  be  less  dangerous  than  slow.  In  proof  of 
this,  I  may,  in  conclusion,  mention  that  I  have  knowledge  of  the 
•case  of  a  girl,  aged  twelve  years,  into  whose  bladder  a  pair  of 
sequestrum  forceps  was  pushed,  a  calculus  seized  and  extracted 
"vi  et  armis^  dilating  and  lacerating  the  urethra  as  it  came.  The 
stone  was  as  large  as  a  pigeon's  Q^g.  Absolute  incontinence  existed 
for  twelve  days,  but  was  followed  by  recovery. 

Stone  sacculated  in  the  Bladder  of  a  Female.  (By  Charles  Will- 
iams, F.  R.  C.  S.,  Ed.,  Surgeon  to  the  JSTorfolk  and  JSTorwich  Hos- 
pital).— Cases  in  which  a  vesical  calculus  is  impacted  in  a  cyst  situated 
in  the  walls  of  the  bladder  are  so  extremely  rare  that  I  consider  it 
a  duty  to  record  this  very  interesting  example : 

A  ■  fine,  healthy  girl,  aged  three  years,  living  in  ISTorwich,  came 
Tinder  the  care  of  the  late  Mr.  George  Hutchison  in  the  year  1873, 
having  for  several  months  previously  suffered  from  very  decided 
symptoms  of  stone  in  the  bladder.  It  had  been  noticed  by  her 
mother  that  from  the  time  of  her  birth  she  had  experienced  diffi- 
culty, as  well  as  occasionally  severe  pain  in  passing  urine,  and  that 
sometimes  she  voided  blood  mixed  with  it,  and  was  in  the  habit  of 
straining  so  violently  as  to  produce  prolapsus  of  the  rectum. 

On  sounding  the  bladder,  which  was  an  unusually  capacious  one, 
it  was  with  some  difficulty  that  a  calculus  could  be  detected.  At 
the  wish  of  the  parents  Mr.  Hutchison  resolved  to  remove  the  stone 
by  dilatation.  Mr.  W.  H.  Day  assisted  at  the  operation,  and  I  was 
requested  to  administer  chloroform.  The  urethra  was  freely  and 
quickly  dilated  with  Weiss's  trivalve  dilator.  There  was  considera- 
ble trouble  to  lind  the  stone,  and  when  found  a  still  greater  trouble 
to  seize  it  "with  the  forceps,  (and  it  was  particularly  noticed  that, 
although  the  patient  was  thoroughly  under  the  influence  of  the 
anaesthetic,  the  getting  hold  of  the  stone  with  the  forceps  occasioned 
severe  straining) ;  the  blades  could  not  be  made  to  grip  the  calcu- 
lus ;  they  continually  slipped  oil,  bringing  away  pieces  of  the  stone. 
At  last  it  became  absolutely  necessary  to  ascertain  what  occasioned 
the  difficulty.  For  this  purpose  the  urethra  was  still  further  dilated, 
and  the  neck  of  the  bladder  was  also  divided  with  a  probe-pointed 
bistoury.     The  stone  could  now  be  felt  with  the  point  of  the  finger 


844  DISEASES   OF  WOMEN. 

immovably  fixed  in  the  floor  of  the  bladder  on  the  patient's  left.  It 
appeared  to  be  of  the  size  of  a  pigeon's  egg,  and  was  inclosed  in  a 
sac,  through  the  neck  of  which  a  small  portion  protruded  into  the 
vesical  cavity,  and  it  was  off  this  nodule  that  the  forceps  so  continu- 
ously slipped.  Many  efforts  were  made  to  dislodge  it — first  with  a 
scoop,  then  with  the  finger,  which  could  barely  reach  it,  and  next 
with  the  forceps ;  they  all  proved  unsuccessful.  Several  portions 
were  broken  off  the  uncovered  portion,  but  the  main  piece  was  left 
in  situ,  as  it  was  considered  undesirable  to  make  any  further  at- 
tempt to  remove  it,  the  patient  having  been  a  long  time  under  the 
influence  of  chloroform,  and  ap^jarently  in  a  very  exhausted  con- 
dition. 

The  next  day  the  child  had  voided  very  little  urine.  A  catheter 
was  introduced,  and  a  small  quantity  of  sanguineous  urine  flowed 
out.  She  was  very  drowsy,  and  had  been  so  since  the  operation. 
When  aroused  she  took  milk  and  brandy  very  freely,  but  immedi- 
ately afterward  became  drowsy  again.  She  did  not  ajjpear  to  have 
recovered  from  the  influence  of  the  chloroform.  The  next  day  she 
died.     No  post-mortem  examination  was  permitted. 

I  am  induced  to  believe  that  this  child  died  of  chronic  chloroform- 
poisoning,  and  not  from  the  effects  of  the  operation,  which  was  by 
no  means  roughly  performed,  and  that  there  was  very  little  blood 
lost.  She  never  thoroughly  revived,  but  became  comatose,  and  died 
in  that  condition.  It  is  difticult  to  imagine  what  could  have  griven 
rise  to  the  formation  of  the  sac.  There  never  was  an  obstruction  to 
the  escape  of  the  urine,  such  as  stricture  or  prostatic  enlargement 
might  engender,  for  neither  existed.  We  are  taught  that  a  cyst  is 
usually  formed  by  the  straining  necessary  to  expel  the  urine ;  the 
mucous  membrane  is  forced  between  the  bands  of  muscular  fibers, 
hypertrophied  in  consequence  of  the  strain  to  which  they  are  sub- 
jected. Nothing  of  the  sort  can  apply  in  this  case,  and  it  is  not  easy 
to  believe  that  the  stone  was  the  cause  of  the  cyst,  which  it  might 
have  been,  had  it  been  situated  close  to  the  neck  of  the  bladder. 
When  impacted  in  this  situation,  the  very  pressure  to  which  a  stone 
is  subjected  by  the  constant  and  long-continued  action  of  the  bladder 
to  expel  it,  causes  the  mucous  membrane  to  ulcerate  through,  and 
the  stone  is  in  due  time  forced  into  a  cavity,  which  enlarges  as  the 
stone  grows,  and  in  this  way  it  may  form  a  tumor  in  the  vagina.  An 
effort  is  then  made  by  nature  to  contract  the  opening,  which  in  this 
child  was  nearly  accomplished  ;  but  the  calculus  was  far  from  the 
neck  of  the  bladder,  and  could  barely  be  touched  with  the  point  of 
the  finger,  so  that  a  different  explanation  of  the  formation  of  the 


NON-INFLAMMATORY  DISEASES   OF  TUE   BLADDER.       845 

cyst  is  required  ;  and  as  no  examination  was  allowed  to  Ije  made,  it 
seems  to  me  to  be  almost  impossible  to  suggest  in  what  way  tbe  sac 
was  formed.  Sabulous  matter,  or  a  few  urinary  crystals,  may  prob- 
ably have  been  deposited  originally  in  a  mucous  follicle,  lacuna,  or 
fossa,  and  gradually  augmented  in  quantity,  and  in  this  way  tbe  sac 
inclosing  tbe  calculus  may  bave  been  produced.  Tbe  mother  of  tbe 
girl  at  four  years  of  age  suffered  from  stone,  wbicb  was  removed  by 
tbe  late  Dr.  Edward  Lubbock ;  it  was  tbe  size  and  shape  of  a  wal- 
nut.    She  has  suffered  from  incontinence  since  that  time. 

I  believe  tbat  it  would  bave  been  very  mucb  better  to  bave  re- 
moved tliis  stone  by  cystotomy.  Had  the  patient  lived  sbe  would 
bave  suffered  from  injured  urethra. 

{c)  Foreign  Bodies  introduced  into  the  Bladder  through  the  Urethra. 
— Of  these  it  may  be  truly  said  tbat  "tbeir  name  is  legion,"  for  in 
tbe  literature  of  tbe  subject  we  find  recorded  a  most  numerous  and 
diverse  bst  of  objects  found  in  tbe  bladder  of  tbe  female.  Some  of 
these  objects  were  forced  into  tbe  bladder  by  accidents,  such  as  falls 
or  blows  ;  others  were  intentionally  introduced  into  tbe  urethra  for 
tbe  purpose  of  masturbation,  and  then  pushed  or  drawn  into  the 
bladder.  Tbe  same  may  occur  in  auto-catbeterization,  the  instru- 
ment being  sometimes  broken  off  in  tbe  bladder,  and  at  others, 
drawn  bodily  into  tbe  viscus. 

Hysterical  and  foolish  women,  with  or  without  tbe  intention  of 
masturbating,  bave  passed  all  manner  of  things  into  tbe  bladder,  as 
pins,  needles,  matches,  sand,  charcoal,  bits  of  glass,  bodkins,  and 
tooth-brush  handles. 

Masturbators  have  also  forced  in  various  articles,  such  as  twigs, 
small  wax  candles,  penholders,  nails,  pencils,  and  tbe  like.  Cathe- 
ters and  clay-pipe  stems,  tbat  bave  been  used  for  purposes  of  cathe- 
terization, have  been  broken  off  and  left  in  tbe  bladder. 

Pessaries,  which  have  been  badly  fitted,  or  worn  too  long,  have 
passed  by  ulceration  from  the  vagina  into  the  bladder. 

Sym])toinatology. — Tbe  symptoms  need  not  be  given  in  detail,  as 
they  are  tbe  same  as  those  caused  by  any  foreign  body,  usually  aggra- 
vated, however,  if  the  body  be  sharp  and  bave  jagged  edges.  Bleed- 
ing is  not  uncommon,  and  pain  varies  in  amount  and  severity  with 
the  kind,  size,  and  shape  of  tbe  foreign  body.  Hysterical  women 
have  been  known  to  conceal  tbe  pain  and  tenesmus  for  a  long  time. 
If  the  bodies  be  small  and  blunt,  they  may  give  rise  to  but  little 
pain  or  tenesmus,  and,  remaining  in  tbe  bladder  undisturbed,  form 
nuclei  for  calculi.  I  doubt  if  a  modification  of  tbe  urinary  secretion 
by  reflex  nerve  influence  (excited  by  these  bodies)  is  necessary  to 


846  DISEASES  OF  WOMEI^. 

cause  incrustation,  or  form  calculi.      The  hypersecretion  of  mucus 
and  decomposition  of  urine  is  all  that  is  required. 

Treatment. — The  treatment  of  a  foreign  body  in  the  bladder  is 
summed  up  in  two  words — remove  it.  This  must  first  be  tried 
through  the  urethra.  A  pair  of  forceps  (those  kno\vn  as  the  alli- 
gator forceps  being  the  best)  are  guided  to  the  object,  which  is  to  be 
seized  and  removed.  If  this  is  difficult,  the  operation  may  be  done 
through  the  speculum.  If  the  bodies  be  small,  they  may  possibly 
be  washed  out.  If  they  are  so  situated  that  their  removal  by  the 
urethra  is  impossible,  vaginal  cystotomy  may  be  performed,  and  the 
foreign  bodies  thus  removed,  using  such  after  treatment  as  will  re- 
lieve any  cystitis,  which  may  have  been  produced. 


CHAPTER  XLYL 

NON-ESTFLAJVUyiATORT  DISEASES  OF  THE  BLADDER    (cONTDTUED), 

BTTPTURE  OF  THE  BLADDER. 

Rupture  of  the  bladder  may  be  classified  according  to  its  loca- 
tion and  extent,  as  follows  : 

I.  Complete  and  incomplete. 

II.  (a)  Occurring  at  a  point  where  the  bladder  is  cohered  with 
peritonaeum. 

(h)  Where  the  bladder  is  not  covered  with  peritoneenm. 

I.  In  the  complete  rapture  all  the  coats  of  the  organ  are  divided, 
while  in  the  incomplete  variety  one  coat  at  least  remains  undivided. 

Pathology. — The  complete  form  of  rupture  is  the  most  common, 
and  the  location  at  which  it  most  frequently  occurs  is  the  posterior 
and  upper  part ;  that  is,  the  part  where  the  walls  of  the  bladder  are 
the  thinnest,  and  probably  where  there  is  the  greatest  exposure  to 
the  causes  of  the  injury. 

There  is  another  reason  given  why  rupture  is  more  frequent 
where  the  bladder  is  covered  with  peritonaeum,  and  that  is  because 
the  peritoneal  covering  is  not  so  elastic  as  the  other  coats. 

When  the  laceration  occurs  within  the  limits  of  the  peritoneal 
coat,  and  is  complete,  the  urine  escapes  into  the  peritoneal  cavity, 
and  produces  shock  and  peritonitis,  which  usually  prove  fatal. 

In  rupture  at  any  point  not  covered  with  peritonaeum,  infiltra- 
tion of  urine  takes  place  in  the  tissues  beneath,  not  within,  the  peri- 
tonseum.  This  infiltration  is  sometimes  very  great,  extending  from 
the  cellular  tissue  of  the  pelvis  to  the  labia  and  thighs. 

The  clinical  history  of  these  two  varieties  differs  in  its  char- 
acteristics because  of  the  fact  just  mentioned — that  in  the  one  va- 
riety the  urine  escapes  through  the  rupture  into  the  peritoneal  cavity, 
while  in  the  other  the  urine  infiltrates  the  tissues  in  and  about  the 
pelvis, 

847 


848  DISEASES   OF  WOMEN. 

In  the  one,  peritonitis  is  speedily  developed,  as  a  rule,  and  gen- 
erally proves  fatal ;  in  the  other,  the  progress  is  slower,  and  the 
chief  danger  is  from  septictiemia.  There  is  another  class  of  cases 
having  a  pathological  history  which  holds  an  iDtermediate  position 
between  the  two  already  described. 

In  this  class  the  history  points  to  the  fact  that  the  rupture  has 
been  at  a  point  destitute  of  peritonaeum,  or  else  the  rupture  has  been 
incomplete,  not  involving  the  peritonaeum. 

This  gives  rise  to  symptoms  of  severe  internal  injury,  but  less 
severe  than  in  complete  rupture,  which  is  followed  by  a  sudden  giv- 
ing way  and  escape  of  urine  into  the  peritoneal  cavity,  and  subse- 
quent peritonitis.  This  opening  into  the  peritoneal  cavity  at  a  pe- 
riod remote  from  the  injury,  is  due  to  pressure  or  ulceration  or 
sloughing,  which  completes  the  rupture. 

Symjptoinatology.  —  Y^Q  symptoms  of  rupture  of  the  bladder  are 
ordinarily  developed  as  follows :  There  is  usually  shock  in  a  mai'ked 
degree,  and  if  the  pelvic  bones  are  broken — a  frequent  comj)lication 
of  this  injury — the  patient  is  unable  to  move  after  having  rallied 
from  the  shock.  Severe  pain  is  felt  in  the  hypogastric  region,  and 
a  continual  desire  to  urinate,  without  the  power  to  void  the  smallest 
quantity  of  urine,  or  possibly  but  a  few  drops  mixed  with  blood. 
The  constitutional  symptoms  indicate  great  prostration,  which  rapidly 
ensues.  The  patient  has  an  anxious  look,  the  countenance  is  pale, 
the  pulse  feeble  and  fluttering,  respiration  sighing,  skin  clannny  ;  the 
abdomen  in  a  short  time  becomes  tympanitic.  There  is  also  a  rise 
in  temperature  after  a  time,  but  during  the  shock  the  temperature 
may  be  sub-normal ;  delirium,  convulsions,  and  coma  may  occm*,  and 
death  may  take  place  in  a  few  hours  in  severe  cases,  or  it  may  be 
delayed  a  few  days.  A  fatal  result  occurs  sooner  in  complete  than 
in  incomplete  rupture. 

If  the  patient  survives  the  shock  or  collapse,  life  may  be  en- 
dangered by  the  development  of  peritonitis  or  septic<\?mia.  The 
physical  signs  of  rupture  are  few  and  by  no  means  reliable.  I  must 
therefore  give  more  attention  to  the  clinical  history  and  symptoms, 
'.ncidentally  bringing  out  the  only  physical  signs  obtainable,  such  as 
the  empty  state  of  the  bladder  found  when  that  viscus  has  not  been 
emptied  in  several  hours,  and  the  withdrawal  of  a  small  quantity  of 
bloody  urine  by  means  of  the  catheter. 

The  surgeon  is  not  able  to  make  a  certain  diagnosis  in  all  cases, 
as  the  symptoms  are  not  always  pathognomonic.  The  statement  of 
the  patient  that  she  received  a  blow  ov^er  the  hypogastrium,  or  that 
while  in  the  act  of  straining  she  felt  something  give  way,  are  valu- 


NON-INFLAMMATORY  DISEASES   OF   THE  BLADDER.       849 

able  as  evidence  when  acute  pain  and  other  symptoms  of  rupture 
follow. 

The  evidence  obtained  from  tlie  use  of  the  catheter  is  of  value, 
especially  when  it  is  known  that  the  patient  had  not  urinated  for 
several  hours  prior  to  the  accident. 

Under  these  circumstances  when  the  bladder  may  contain  a 
small  quantity  of  bloody  urine  or  when  the  bladder  is  empty,  there 
is  strong  evidence  of  the  bladder  being  lacerated.  But  the  evidence 
pointing  to  rupture  is  by  no  means  always  certain.  And  again  very 
often  signs  and  symptoms  which  the  diagnostician  depends  upon 
most  are  absent,  and  those  that  are  present  are  Hable  to  mislead. 
This  is  very  unfortunate,  but  true.  The  diagnosis  is  especially  ob- 
scure when  there  has  been  a  long  interval  between  the  receipt  of  the 
injury  and  the  development  of  characteristic  symptoms.  It  is  there- 
fore necessary  to  watch  a  patient  in  whom  there  is  suspicion  that 
rupture  of  the  bladder  may  have  occurred.  The  symptoms  may  be 
for  a  time  concealed  and  then  develop  rapidly.  The  first  symptoms 
may  be  delayed  or  be  obscure  and  not  attract  attention,  because  the 
vesical  rupture  may  be  involved  with  other  injuries  whose  symp- 
toms for  the  time  hide  the  more  dangerous  lesions.  As  a  rule,  it  is 
rare  to  find  any  external  signs  or  mark  of  injury  on  examination  of 
the  abdomen.  When  much  depends  on  the  history  given  by  the 
patient  regarding  the  nature  of  the  accident  and  the  condition  of 
the  bladder  at  the  time,  it  frequently  happens  that  she  is  not  able 
to  answer  questions  correctly,  because  of  the  shock  and  the  fact  that 
this  accident  often  occurs  while  the  patient  is  intoxicated. 

Strange  as  it  may  appear,  in  exceptional  cases  the  patient  may 
have  uo  difiiculty  in  urinating,  and  indeed  may  pass  a  large  quan- 
tity of  water.  Cases  have  been  recorded  where  the  patient  regained 
the  power  of  voluntary  urination  after  the  catheter  was  passed  for 
the  first  time.  * 

Although  it  is  important  to  make  a  diagnosis  early  in  all  cases, 
yet  it  is  of  equal  importance  to  know  whether  the  rupture  is  com- 
plete or  incomplete.  This  can  be  done  by  noting  the  fact  that  in 
the  one  case  there  will  be  infiltration  of  the  urine  into  the  cellular 
tissue  of  the  pelvis,  and  in  the  other  such  infiltration  is  absent. 

It  is  often  necessary  to  pass  the  catheter  both  for  diagnosis  and 
treatment,  and  great  care  should  be  taken  in  its  introduction,  for 
sometimes  by  using  too  much  force  it  is  accidently  pushed  through 
the  viscus  into  the  abdominal  cavity. 

Prognosis. — The  chances  of  recovery  are  not  favorable,  espe- 
cially when  the  urine  passes  into  the  peritoneal  cavity  through  a 
55 


850  DISEASES   OF  WOMEN. 

rupture  higli  up.  When  the  rupture  is  incomplete  or  does  not  in- 
volve the  peritoneal  coat  and  treatment  is  early  employed,  the  pros- 
pects of  saving  the  life  of  the  patient  are  encouraging. 

Causation. — The  predisposing  causes  of  rupture  are  certain  con- 
ditions of  the  walls  of  the  bladder,  such  as  atrophy,  fatty  degenera- 
tion, ulceration,  and  sacculation ;  overdistention  from  stricture  or 
other  causes,  and  alcoholic  intoxication  which  favors  overdisten- 
tion, and  exposure  to  the  exciting  causes  of  the  accident.  The 
empty  bladder  may  be  lacerated  in  connection  with  injuries  of  the 
other  pelvic  organs,  but  it  is  a  fact  that  in  the  majority  of  cases  the 
bladder  has  been  less  or  more  distended  at  the  time  of  the  accident. 
It  should  be  borne  in  mind,  however,  that  rupture  has  occurred  a 
great  many  times  when  the  bladder  was  normal  and  not  overdis- 
tended,  there  being  no  predisposing  conditions  present  that  could 
be  recognized.  The  most  common  determining  causes  are  blows 
over  the  region  of  the  bladder.  These  may  be  sustained  in  a 
variety  of  ways,  such  as  direct  blows  or  knocks,  falling  from  a 
height  upon  something  which  violently  strikes  upon  the  hypogas- 
trium.  Kupture  often  occurs  in  connection  with  severe  injuries 
which  fracture  the  pelvic  veins.  In  such  cases  it  is  not  possible  to 
say  whether  the  rupture  occurring  under  such  circumstances  is  due 
to  the  direct  blow  or  to  laceration  by  pieces  of  the  broken  bones. 

Rupture  has  occurred  sufficiently  often  in  the  puerperal  state  to 
warrant  placing  this  condition  in  the  list  of  predisposing  causes. 
One  can  see  how  a  distended  bladder  might  be  ruptured  during 
the  violent  labor -pains  or  the  contortions  of  instrumental  and 
manual  delivery,  and  this  accident  has  occurred  in  that  way.  In 
a  number  of  cases,  however,  the  rupture  has  not  taken  place  un- 
til after  delivery,  showing  that  the  labor  gave  rise  to  retention,  and 
that  to  rupture.  So  far,  then,  as  the  puerperal  state  is  related  to 
rupture  of  the  bladder  it  may  be  said  that  a  full  bladder  may  be 
ruptured  by  the  direct  violence  done  during  delivery,  but  quite  as 
often  retention  occurs  in  the  puerperal  state,  and  the  rupture  is 
caused  by  overdistention.  In  a  similar  way  rupture  has  occurred 
in  displacement  of  the  uterus  which  caused  retention  of  the  urine. 

The  bladder  has  frequently  been  wounded  during  ovariotomy 
and  hysterectomy  when  there  were  adhesions,  but  this  accident  does 
not  come  under  the  head  of  rupture  now  under  consideration. 

Treatment. — The  first  indications  are  to  relieve  pain  and  shock 
if  either  is  present.  These  objects  can  be  attained  usually  by  opium 
and  stimulants.  If  there  is  infiltration  of  urine  into  the  pelvic 
cellular  tissue  the  urine  should  be  removed  by  puncturing  or  incis- 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       851 

ing  the  parts  affected.  Next,  and  most  important  of  all,  the  bladder 
should  be  continuously  kept  empty  by  retaining  the  catheter  in 
the  bladder.  The  catheter  should  be  a  flexible  one  of  soft  rubber 
with  a  perfect  eye  very  near  the  end.  It  should  be  made  to  enter 
the  bladder  only  far  enough  to  secure  perfect  drainage  and  not  far 
enough  to  disturb  the  wound  in  the  bladder.  Yaginal  cystotomy 
has  been  recommended  as  a  means  of  drainage,  but  I  feel  sure  that 
the  catheter  is  a  simpler,  and  certainly  as  reliable  a  means  of  accom- 
phshing  the  object.  The  management  of  the  graver  cases,  in  which 
the  rupture  opens  into  the  peritoneal  cavity,  must  be  of  the  most 
heroic  character  in  order  to  be  effectual. 

The  great  object  is  to  cleanse  the  peritoneal  cavity  of  urine  and 
blood.  This  has  been  done  when  the  case  was  seen  early,  by  pass- 
ing the  catheter  into  the  peritoneal  cavity  through  the  rent  in  the 
bladder.  When  this  can  be  done  easily  it  may  answer  that  purpose, 
and  the  patient  may  be  treated  by  rest  and  opium ;  but,  unless  the 
catheter  passes  without  much  effort  and  the  one  catheterization  is 
sufficient,  this  method  should  not  be  persisted  in. 

Laparotomy  appears  to  offer  the  best  chances  in  these  very  for- 
midable cases.  If  the  patient  is  seen  early,  and  before  extensive 
peritonitis  has  been  established,  I  believe  the  best  that  can  be  done 
is  to  open  the  abdominal  cavity,  and  thoroughly  remove  all  blood 
and  urine  that  have  accumulated.  When  this  has  been  accom- 
plished the  wound  in  the  bladder  should  be  accurately  closed  with 
sutures.  In  case  the  edges  of  the  wound  are  very  irregular,  and 
will  not  fit  together  accurately,  they  should  be  trimmed  suffi- 
ciently to  give  a  clean  and  complete  coaptation.  The  after-treat- 
ment should  then  consist  in  draining  the  bladder,  as  already 
mentioned,  and  managing  the  patient  as  in  laparotomy  for  any 
purpose. 

ILLUSTRATIVE    CASES. 

Case  of  Rupture  of  Female  Bladder  associated  with  Abortion  (by  T. 
Lawrie  Gentles,  L.  F.  P.  S.  G.,  Derby).— On  October  13th  I  was 
requested,  at  3  a.  m.,  to  visit  a  woman  in  a  neighboring  street,  who 
was  said  by  the  messenger  (her  husband)  "to  have  had  a  mishap." 

On  reaching  the  house  I  found  a  well-made  woman  of  thirty-six 
lying  on  her  left  side  in  bed,  vomiting  large  quantities  of  a  dark- 
brown,  pungent-smelling  liquid.  The  pillows  were  drenched  with 
the  fluid,  so  also  was  the  carpet  in  front  of  the  bed,  and  on  the  walls 
opposite  to  the  patient  were  stains  of  a  similar  nature.  There  was 
also  half  a  pint  of  vomit  in  the  chamber-vessel.     The  woman  was  in 


852  DISEASES   OF  WOMEN. 

a  state  of  collapse ;  a  cold,  clammy  perspiration  stood  on  her  face, 
her  hands  and  feet  were  like  ice,  and  her  pulse  was  impercei^tible. 
There  was  no  one  in  the  house  except  her  husband  and  two  little 
children,  the  latter  occupying  the  same  bed  as  the  patient ;  while,  to 
add  still  more  to  the  ghastliuess  of  the  scene,  the  younger  of  the 
children  (a  babe  of  nine  months)  was  vainly  endeavoring  to  reach  its 
dying  mother's  breast  in  order  to  obtain  its  usual  nourishment. 

I  made  a  rapid  examination  by  the  vagina,  but  found  a  closed 
OS  uteri,  and  no  marked  traces  of  haemorrhage.  I  observed,  however, 
that  the  abdomen  was  greatly  distended.  I  tried  to  administer  some 
ammonia,  but  the  patient  was  unable  to  swallow ;  she  gave  me  one 
agonizing  look  of  dread,  moved  her  lips  as  if  to  sjDeak:,  and  then  died, 
tlie  death  taking  place  within  a  quarter  of  an  hour  after  my  arrival 
at  the  house. 

My  first  impression  was  that  the  woman  had  died  of  internal 
haemorrhage ;  the  only  things  which  seemed  to  militate  against  tliis 
being  the  redness  of  the  lips  and  the  copious  vomiting.  This  idea 
of  hsemorrhage  seemed  also  confirmed  by  what  the  husband  said  at 
the  bedside — viz.,  that  "  his  wife  had  had  a  good  many  clots  come 
from  her,  and  that  her  linen  was  very  much  stained." 

I  refused,  of  course,  to  give  any  certificate,  and  communicated 
with  the  coroner.  In  collecting  evidence  for  the  inquest,  the  follow- 
ing facts  were  clearly  brought  out ;  first,  that  the  woman  was  a 
drinker ;  secondly,  that  she  had  had  a  drinking-bout  for  some  days ; 
and  thirdly,  that  she  had  had  occasional  difliculty  in  passing  urine. 
In  regard  to  the  first  two  points,  the  husband's  evidence  was  most 
conclusive,  and  showed  clearly  that  when  the  poor  woman  had  one 
of  her  drinking-fits  on,  she  would  not  only  consume  large  quantities 
of  beer  (her  favorite  drink),  but  also  all  the  spirituous  liquors  she 
could  lay  her  hands  on.  In  regard  to  the  third  point,  the  hus- 
band also  made  clear  the  fact  that  his  wife  had  often  suffered  from 
retention  of  urine,  but,  "so  far,  had  always  got  over  it."  At  the 
inquest,  further  details  of  evidence  brought  to  light  the  fact  that  the 
woman  had  complained  of  pain  in  her  belly  for  two  or  three  days 
previous  to  death.  She  had,  however,  been  "up  and  down  stairs" 
until  1  p.  M.  of  the  day  preceding  her  death ;  but  when  her  husband 
came  home  at  6  p.  m.,  he  found  her  in  great  pain,  and  was  told  by 
his  wife  that  "she  had  been  losing  blood."  A  good  many  clots 
were  in  the  chamber-vessel,  and  these  he  threw  away  into  the  ash- 
pit. The  pain  getting  no  better,  and  finding  that  his  wife  was 
"  altering  for  the  worse,"  he  came  for  a  medical  man  as  already 
stated. 


NON-INFLAMMATORY  DISEASES   OF   THE   BLADDER.       853 

At  tlie  autopsy  there  were  no  external  signs  of  violence  found, 
except  a  slight  abrasion  on  the  forehead,  and  another  on  the  lower 
lip,  and  a  small  bruise  on  the  inner  side  of  the  right  thigh,  none  of 
which  were  of  recent  date.  On  cutting  through  the  abdominal  walls, 
the  great  depth  of  fat  and  its  extreme  "  watenness  "  arrested  our  at- 
tention, the  knife  going  through  the  tissue  with  a  distinct  "  swish." 
Suspecting  an  accumulation  of  fluid  in  the  abdominal  cavity,  a  small 
incision  was  made  at  first.  No  sooner  was  this  done  than  a  reddish- 
brown  liquid  began  to  well  up.  Some  of  this  was  drawn  off,  and  the 
opening  enlarged,  when  nearly  six  pints  of  fluid  were  removed.  The 
stomach  and.  intestines,  having  been  carefully  examined,  were  then 
taken  out,  in  order  to  facilitate  further  search  for  the  lesion.  The 
flrst  thing  which  we  noticed  was  a  pint  of  blood  lying  in  the  pelvic 
basin ;  and,  on  making  more  minute  search,  a  rent  was  discovered  in 
the  posterior  wall  of  the  bladder — a  rent  large  enough  to  admit  four 
fingers.  Here,  then,  was  the  cause  of  death.  There  were  some 
fresh  adhesions  on  each  side  of  the  bladder  and  the  pelvic  walls; 
there  were  also  similar  adhesions  between  the  bladder  and  uterus. 
All  these  adhesions,  however,  were  extremely  soft,  and  broke  with 
the  slightest  pressure.  The  walls  of  the  bladder  itself  also  seemed 
much  thinner  than  usual.  No  flakes  of  lymph  could  be  discovered 
in  the  fluid  removed  from  the  abdominal  cavity,  and  neither  did 
the  peritonseum  exhibit  any  great  degree  of  vascularity.  It  may  be, 
however,  I  think,  safely  affirmed  that  a  large  portion  of  the  fluid 
found  was  effused  from  an  irritated  peritonaeum,  the  other  portion 
of  the  fluid  being,  of  course,  urine  from  the  ruptured  bladder. 

On  opening  the  uterus,  signs  of  recent  delivery  presented  them- 
selves ;  on  observing  which  I  asked  my  son  to  tell  the  husband  to 
rake  up  "  the  clots  "  from  the  ash-pit.  The  husband  did  so,  and  one 
of  the  "clots"  was  found  to  be  a  foetus,  three  inches  in  length. 

Now  comes  the  question :  When  did  the  rupture  of  the  bladder 
occur,  and  had  uterine  action  anything  to  do  with  it  ?  Supposing 
that  the  "  pains  in  the  belly,"  of  which  the  woman  complained  for 
two  or  three  days  before  death  were  the  commencement  of  the 
abortion,  it  is  reasonable  to  infer  that,  when  true  expulsive  efforts 
on  the  part  of  the  uterus  began,  these  efforts  would  be  aided  by  the 
action  of  the  abdominal  muscles ;  and,  supposing  still  further,  that 
the  bladder  was  at  that  time  distended  to  its  fullest  capacity,  it  is 
perfectly  possible  that  the  pressure  of  the  abdominal  muscles  would 
be  the  "last  straw"  necessary  to  produce  the  fatal  lesion.  I  am, 
therefore,  inclined  to  think  that  the  rupture  took  place  in  the  after- 
noon of  the  12th.     I  ought  to  have  stated  that,  although,  when  the 


854  DISEASES   OF  WOMEN. 

husband  came  home  at  6  p.  m.  on  that  day  he  found  his  wife  in  bed, 
she,  nevertheless,  "  kept  getting  out  of  bed,  trying  to  pass  urine,  but 
could  not."  There  can  be  little  doubt  that  the  alcoholic  condition 
of  the  patient  would  rob  her  of  her  sense  of  attending  to  the  calls  of 
nature ;  and  it  is  melancholy  to  think  that,  if  she  had  only  been  seen 
earlier,  a  simple  catheterism  might  have  saved  her. 

As  a  piece  of  concurrent  evidence  of  the  habits  of  the  patient,  it 
may  be  stated  that  the  liver  was  a  genuine  "  nutmeg " ;  that  the 
kidneys  were  thoroughly  disorganized  (the  cortical  substance  being 
rarely  distinguishable);  and  that  the  spleen  was  exceedingly  soft. 
The  heart  was  small  and  fatty.  The  lungs  were  fairly  healthy,  but 
there  were  extensive  adhesions  in  the  right  pleural  cavity.  The 
head  was  not  examined. — British  Medical  Journal,  January  6, 
1883. 

Cases  of  Rupture  treated  by  Laparotomy. — (A.  G.  Walter) — Ten 
hours  after  a  severe  injury,  no  urine  was  found  by  the  catheter.  The 
abdomen  was  opened  in  the  linea  alba  by  an  incision  beginning  one 
incli  below  the  umbilicus  and  terminating  one  inch  above  the  pubes, 
to  the  extent  of  six  inches.  The  intestines  were  found  inflated, 
their  peritoneal  coat,  as  well  as  that  hning  the  interior  of  the  ab- 
dominal walls,  already  showing  evident  marks  of  congestion.  A 
soft  sponge  was  then  cautiously  introduced  into  the  abdomen,  with 
which  the  extravasated  fluid,  consisting  of  urine  and  blood,  was 
carefully  removed  from  the  pelvis  and  between  the  convolutions  of 
the  bowels,  amounting  to  nearly  a  pint.  A  rent  was  found  at  the 
fundus  of  the  bladder,  two  inches  in  extent.  The  cavity  of  the  ab- 
domen being  cleansed  of  the  noxious  agent,  the  wound  of  the  blad- 
der was  left  to  itself,  as  no  urine  was  seen  to  escape  from  it.  The 
abdominal  wound  was  closed  by  strong  Carlsbad  needles,  secured  by 
silver  wire  (only  skin  and  fascia  being  stitched,  while  the  peritonaeum 
was  left  untouched) ;  a  flannel  bandage  encircled  the  whole  abdomen. 
The  patient,  awakenirg  from  the  anaesthetic  sleep,  felt  relieved  of 
pain  and  the  desire  to  urinate,  so  distressing  before  the  operation  ; 
vomiting  did  not  return ;  opium  in  one-grain  doses  was  ordered ; 
abstinence  of  drink  and  perfect  quietude  of  body,  with  retention  of 
the  catheter,  were  sti-ictly  insisted  upon.  lie  soon  began  to  doze, 
had  a  comfortable  night,  was  free  from  pain  the  next  morning,  com- 
plaining only  of  soreness  in  the  abdomen,  without  tympanites,  sick- 
ness, or  calls  to  urinate ;  thirst  less  urgent.  The  treatment  being 
vigorously  continued,  for  drinks  iced  barley-water,  water  only  in 
very  small  quantities,  with  pieces  of  ice,  being  allowed.  No  un- 
pleasant symptom  followed ;  urine  in  small  quantities,  but  free  of 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER.       855 

the  admixture  of  blood,  passing  by  the  catheter.  On  the  third  day 
the  intervals  between  the  doses  of  opium  were  lengthened  to  two 
hours;  on  the  fifth,  to  three,  and  thus  gradually  decreased  as  all  signs 
of  iniiammation  had  passed.  At  the  end  of  a  week  the  abdominal 
wound  a2:)peared  to  be  closed  by  first  intention ;  the  stitches,  however, 
were  not  removed  till  a  week  later.  The  gum-elastic  catheter  was 
replaced  by  a  new  one  every  two  days,  and  was  not  withdrawn  for 
two  weeks  after  the  injury  had  been  received,  and  then  only  for  a 
short  time.  At  the  expiration  of  two  weeks,  with  the  absence  of  all 
pain  and  tenderness,  opium  was  omitted.  The  intestines  were  re- 
lieved by  warm-water  injections  on  the  tenth  day,  when  mild  nour- 
ishment was  ordered.  Between  the  second  and  third  week  the 
catheter  was  permanently  withdrawn,  and  only  introduced  every 
four  hours  for  the  evacuation  of  urine.  After  the  third  week,  the 
patient  left  his  bed.  He  has  remained  well,  working  at  his  trade, 
and  feeling  no  impediment  in  his  urinary  organs. 

(Alfred  Willett). — An  incision  some  five  to  six  inches  in  length, 
from  the  umbilicus  to  the  pubes,  was  made  in  the  mesial  line  and 
carried  through  the  parietes.  All  bleeding  points  having  been  se- 
cured, the  peritonaeum  was  opened,  and  at  once  several  ounces  of 
dull,  brownish  fluid,  with  strong  urinous  odor,  escaped.  The  intes- 
tines were  greatly  distended,  and  instantly  bulged  out  through  the 
wound.  The  peritonaeum  generally  was  highly  injected,  and  adja- 
cent surfaces  were  glued  together.  Passing  my  hand  into  the  pelvis 
I  detected  a  laceration  of  the  bladder.  The  coils  of  gut  were  only 
slightly  more  adherent  here  than  in  the  abdomen  proper ;  I  satis- 
fied myself  that  there  was  no  protrusion  of  bowel  into  the  lacerated 
bladder.  The  omentum  was  raised  from  off  the  intestines,  and  so 
much  of  the  latter  as  lay  in  the  pelvis  was  drawn  up,  laid  upon  the 
upper  part  of  the  patient's  abdomen,  and  protected  from  harm  and 
chill  by  flannels  wrung  out  of  moderately  hot  water.  There  was 
about  half  a  pint  of  bloody,  urinous  fluid  in  the  pelvis,  and  when 
this  had  been  sponged  away,  a  rent  of  the  bladder  some  three  and  one 
half  inches  in  extent  was  exposed.  It  extended  diagonally  across  the 
fundus,  having  a  direction  from  before  backward  and  from  right  to  left. 
The  appearance  was  that  of  a  nearly  straight  tear  through  all  the 
coats  of  the  bladder,  except  at  its  most  dependent  parts,  where  it  was 
jagged  and  uneven.  The  bladder  was  flaccid,  but,  of  com'se,  quite 
empty,  and  at  the  site  of  rapture  its  walls  were  fully  haK  an  inch  in 
thickness.  I  brought  the  torn  edges  easily  in  apposition,  and  united 
them  by  eight  interrupted  sutures  of  fine  Chinese  silk.  The  sutures 
were  placed  at  intervals  of  rather  less  than  half  an  inch,  and  seemed 


850  DISEASES   OF   WOMEN. 

to  close  the  rent  completely.  Before  returning  the  intestines  I 
cleaned  out  the  abdomen  as  thoroughly  as  I  was  able ;  but  the  mes- 
entery of  the  gut  lying  outside  the  abdomen  acted  as  a  transverse 
diaphragm,  and  I  was  disappointed  to  find  on  replacing  these  coils 
that  some  of  the  fluid  had  been  pent  up  above  it.  Owing  to  gaseous 
distention,  very  considerable  difficulty  was  experienced  in  replacing 
all  the  intestines  mthin  the  abdomen,  and  I  was  quite  unable  to  in- 
troduce my  hand  and  cleanse  the  upper  part  of  the  peritoneal  cavity 
as  satisfactorily  as  I  could  have  wished  ;  but  tlie  patient's  shoulders 
were  raised  in  order  to  make  the  pelvis  more  dependent,  and  all  fluid 
that  found  its  way  there  was  removed.  The  intestines  that  had  been 
lying  out  of  the  abdomen  during  the  operation  were  sponged  over 
with  warm  water  and  carefully  cleansed  before  returning  them.  So 
extreme  was  their  distention  that  to  enable  me  to  introduce  sutures, 
and  close  the  external  wound,  Mr.  Langton,  who  assisted  me,  was 
obliged  to  spread  out  his  hand  and  restrain  the  bowels  from  forcing 
their  way  through  the  wound,  withdrawing  his  hand  gradually  as  the 
successive  sutures,  also  of  Chinese  silk,  were  tightened.  Through 
the  lower  angle  of  the  abdominal  wound  I  passed  a  carbolized  drain- 
age-tube into  the  pelvis,  securing  it  to  the  edge  of  the  external 
wound,  which  was  then  dressed  precisely  as  after  ovariotomy.  A 
Thompson's  catheter  was  introduced  and  retained  in  the  bladder.  On 
being  replaced  in  bed,  hot  bottles  were  placed  beside  the  patient,  and 
he  was  well  covered  uj).  The  wound  in  the  abdominal  parietes  was 
found  on  the  autopsy  to  be  adherent  almost  'along  its  whole  line  ;  not 
much  swelling  of  abdomen.  The  intestines  immediately  behind  the 
wound  were  adherent  to  it.  All  the  coils  of  intestine  in  the  lower  half 
of  the  abdomen  were  adherent  to  each  other  and  to  the  abdominal 
walls  by  recent  lymph.  The  intestines  in  contact  with  the  bladder 
were  adherent  to  it.  There  were  about  two  ounces  of  bloody  fluid  at 
the  back  of  the  peritoneal  cavity ;  about  an  ounce  of  this  lay  just 
above  the  bladder.  The  opening  in  the  bladder  was  everywhere  well 
closed,  excejit  between  the  posterior  two  stitches,  where  there  was  an 
orifice  through  which  water  injected  per  urethram  escaped  very  freely. 
Even  here  there  appeared  to  be  an  attempt  at  repair.  Elsewhere  the 
edges  of  the  wound  were  adherent.  There  was  very  little  sign  of 
inflammation  in  the  interior  of  the  viscus. 

(Christopher  Heath). — Man,  aged  forty-seven.  Pubes  being 
shaved  and  washed  with  carbolic  lotion,  an  incision  was  made  in  the 
middle  line  just  above  the  pubes  for  two  inches,  and  the  tissues 
di^^ded  down  to  the  peritona'um,  which  appeared  blue,  the  recti  mus- 
cles, which  were  firmly  contracted,  being  held  aside  by  retractors 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER.       857 

with  difficulty.  Tlie  peritonsTeum  was  then  picked  up  and  a  cut  made 
into  it,  when  a  gush  of  fluid,  like  that  di-awn  off  by  the  catheter, 
came  out.  A  large  quantity  of  clots  was  then  taken  out  from  the 
peritoneal  cavity.  The  linger  introduced  into  the  peritoneal  cavity 
found  a  long  rent  in  the  posterior  wall  of  the  bladder  high  up.  This 
was  sewed  up  by  a  continuous  catgut  suture  hrmly  tied  at  both  ends. 
The  clots  were  removed  as  far  as  possible  from  the  peritonaeum,  and 
the  cavity  sponged  out  after  injection  with  warm  water,  and  a  long 
large-sized  drainage-tube  was  inserted  at  the  lower  angle  of  the 
wound,  the  upper  part  of  the  wound  being  brought  together  by  deep 
and  superficial  sutures.  A  catheter  was  passed  into  the  bladder,  to 
which  was  afterward  attached  some  India-rubber  tubing  leading  into 
a  vessel  under  the  bed.  Hot  poultices  were  applied  to  the  abdomen, 
and  one  grain  of  opium  was  administered  every  four  hours.  The  fur- 
ther history  shows  great  relief  and  improvement,  but  on  the  fourth 
day  after  the  operation  the  patient  became  rapidly  worse  and  died. 
Autopsy. — Small  intestines  considerably  distended.  For  two  inches 
around  the  abdominal  wound  the  intestines  were  adherent  by  recent 
lymph  to  each  other,  and  to  the  abdominal  parietes.  Above  and  on 
each  side  of  these  adhesions  there  was  no  trace  of  peritonitis.  On 
tearing  away  these  adhesions  some  coils  of  intestines  were  seen  lying 
over  the  pelvis  glued  together,  and  to  adjacent  parts  by  recent  blood- 
stained lymph.  On  lifting  these  coils  upward,  the  recto-vesical 
pouch  of  peritonseam  was  exposed,  containing  about  six  ounces  of 
clotted  blood,  black  in  color,  and  moderately  offensive  odor.  There 
was  a  rent  in  the  mid  line  of  the  posterior  wall  of  the  bladder  two 
inches  in  length,  extending  upward  as  high  as  the  apex.  The  lower 
third  of  the  rent  was  gaping ;  the  edges  of  the  rest  were  aj)proxi- 
mated  by  the  catgut  suture,  the  lower  end  of  which  was  free  and 
loose. 


CHAPTEK   XLVII. 

NON-INFLAMMATOKY   DISEASES    OF    THE   BLADDER    (CONTINUED). 

NEOPLASMS,  HYPERPLASIA,  ATROPHY. 

Owing  to  the  very  imperfect  facilities  for  observing  the  internal 
surface  of  the  bladder  during  life,  the  study  of  vesical  neoplasms 
up  to  within  a  few  years  was  chiefly  post-mortem,  and  of  course 
their  therapeutics  was  almost  nil.  At  the  present  time,  however, 
by  means  of  the  endoscope,  the  microscope,  and  the  operation  of 
cystotomy,  more  accurate  methods  of  diagnosis  and  of  rational  and 
successful  treatment  have  been  developed. 

The  neoplasms  of  the  bladder  may  be  classified  as  follows  : 

Benign. — Myxoma,  fibroma,  myoma,  myo-fibroma,  tubercle. 

Malignant. — Epithelioma,  encephaloid,  scirrhus,  sarcoma. 

Tumors  of  the  bladder  and  deposits  in  its  walls  are  by  no  means 
common,  and  those  of  a  benign  nature  are  less  common  than  those 
that  are  malignant.  There  has  been  some  dispute  as  to  whether 
some  of  these  neoj^lasms  are  malignant.  This  is  especially  tlie 
case  in  regard  to  the  villous  growth,  the  German  and  some 
English  authorities  ranking  them  as  essentially  malignant,  while 
some  American  authors,  as  Van  Buren  and  Keyes,  deny  in  toto  that 
they  have  any  such  property.  More  will  be  said  of  this  when  I 
come  to  the  class  in  which  I  have  placed  them  ;  not  that  I  am  satis- 
tied  that  they  are  malignant,  but  for  lack  of  positive  evidence  of  the 
new  idea,  temporarily  at  least,  I  adhere  to  the  old  one. 

Benign  Growths. — Myxomata,  Mucous  Polyju,  and  Polypoid  Hy- 
pertrophies, while  having  nearly  the  same  anatomical  characters,  are 
really  different  affections  as  regards  etiology,  sjonptomatology,  prog- 
nosis, and  treatment. 

Mucous  polypi  are  isolated  hypertrophies  of  the  mucous  mem- 
brane, varying  in  size,  and  giving  rise  to  trouble  only  in  proportion 
to  their  size.  They  may  exist  at  birth,  or  be  developed  at  any  time 
during  life,   being  more  common,  however,  in  youth  and  middle 

858 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       859 

age.  The  mucous  membrane  covering  them  is  thickened  and  pulpy, 
and  that  about  their  base  and  in  their  immediate  ueighl:)orhood  is 
somewhat  thickened,  and  more  vascular  than  normal.  If  the  polypi 
are  situated  at  or  near  the  neck,  or  in  other  portions  of  the  bladder, 
where  their  long,  narrow  pedicles  admit  of  a  blocking  of  the  m-ethra, 
the  entire  mucous  membrane  of  the  organ  suffers,  as  in  all  cases  of 
retention  and  decomposition  of  urine.  If  the  obstruction  is  great, 
and  the  organ  requires  spasmodic  and  irregular  muscular  effort  to 
empty  it,  there  will  be,  sooner  or  later,  not  only  cystitis,  but  mus- 
cular as  well  as  mucous  hypertrophy. 

These  growths  may  be  as  small  as  the  head  of  a  pin,  or  as  large  as  a 
goose-egg ;  they  consist  of  hypertrophied  and  hyperplastic  connective 
tissue,  covered  by  soft,  pulpy,  hyioerplastic  mucous  membrane,  that 
bleeds  easily  on  touch.  They  may  coexist  with  uterine  fibroids. 
Their  favorite  seat  is  the  j)osterior  wall  of  the  bladder. 

General  polypoid  hypertrophy  of  the  mucous  membrane  con- 
sists in  an  irregular  thickening  of  the  mucous  membrane  through- 
out, accompanied  as  a  rule  by  hypertroj)hy  of  the  muscular  and 
serous  coats.  There  is  an  increased  blood-suj)ply,  the  membrane  be-' 
ing  bright  red  in  color,  the  capillaries  dilated,  and  the  whole  mass 
bleeding  easily  on  the  touch.  It  has  somewhat  the  appearance  of 
fresh  granulations.  Upon  the  free  surface  of  the  mucous  membrane, 
there  is,  as  we  should  expect,  an  excessive  cell  proliferation,  these 
cells  being  in  a  transitional  condition,  i.  e.,  occupying  the  position 
between  imperfect  and  perfect,  and  not  all  of  the  same  degree  of 
perfection  or  imperfection  of  development.  There  may  be  either 
serous  or  gelatinous  infiltration,  giving  it  a  heavy,  sodden  look. 
Upon  the  surface  are  often  found  incrustations  of  the  urinary  salts. 

It  appears  to  me  that  there  has  been  an  undue  complexity  of 
classification  of  this  subject,  especially  among  the  German  patho- 
logists, some  of  whose  differences  are  too  minute  to  be  of  any  prac- 
tical value  from  either  a  pathological,  diagnostic,  or  remedial  point  of 
view.  Tumors  which  they  call  villous  or  papilloma  vesicae  are,  in 
many,  if  not  all  respects,  identical  with  the  so-called  polypoid  hyper- 
trophy of  the  vesical  mucous  membrane.  For  all  practical  purposes 
they  are  essentially  the  same. 

They  have  been  described  as  enlarged  papillae,  the  vessels  of 
which  are  dilated,  and  their  walls  thinned.  They  only  differ  from 
the  polypoid  hypertrophy  in  increase  of  vascularity,  and  the  fact 
that  they  are  usually  limited  to  the  trigone.  Underlying  and  about 
them  is  a  thin,  wavy  stroma  of  connective  tissue,  that  becomes  in- 
creased as  the  disease  advances. 


860  DISEASES  OF  WOMEN. 

The  surface  of  these  growths  varies  very  much  in  different  cases ; 
in  some  looking  hke  large  granulations,  in  others  having  more  body, 
being  more  compact,  and  looking  somewhat  like  a  I'aspberry  or  mul- 
berry. Occasionally,  they  are  slightly  pedunculated.  Their  surface 
has  an  epithelium  resembling  the  superficial  layer  of  the  bladder, 
unless  proliferation  is  very  rapid,  when  the  cells  lose  their  identity, 
and  take  a  multiplicity  of  forms,  to  which  may  be  attributed,  perhaps, 
their  having  sometimes  been  mistaken  for  cancer  cells  when  found 
in  the  urine.  Fatty  degeneration  of  the  most  superticial  cells  is  by 
no  means  uncommon.  As  the  villi  increase  in  size  and  number,  the 
connective-tissue  stroma,  while  increasing  about  their  base,  dimin- 
ishes in  the  prolongations  themselves,  leaving  little  besides  a  mass 
of  tortuous,  thin-walled,  dilated  vessels  hanging  free  in  the  bladder. 
The  rest  of  the  mucous  membrane  is  usually  soft  and  hyperplastic, 
and,  if  there  be  any  stoppage  to  the  free  outflow  of  urine,  inflamma- 
tion may  coexist,  with  incrustations,  and  possibly  dilatation  of  the 
ureters.     The  muscular  coat  is  also  usually  slightly  hypertrophied. 

Fibroid  tumors  and  myo-fibromata  are  very  rarely  found  in  the 
bladder.  When  they  do  exist  they  have  all  the  characters  of  the 
flbroma  or  myo-fibroma  found  elsewhere,  and  give  rise  to  the  same 
changes  in  the  vesical  walls  and  ureters  that  other  tumors  do,  viz., 
retention  with  hypertrophy,  or  dilatation,  cystitis,  and  inflammation 
of  the  ureter.  They  may  have  their  seat  in  any  part  of  the  bladder- 
wall,  and  occur  at  any  period  of  life. 

Symptomatology. — The  symptoms  of  vesical  neoplasms  are  di- 
visible into  local  and  constitutional ;  the  former  being  by  far  the 
more  important.  The  local  symptoms,  if  the  tumors  be  of  any  size, 
are  those  produced  by  a  foreign  body  in  the  organ,  viz.,  irritation, 
and  sooner  or  later  inflammation. 

Obstruction  to  urination  sometimes  occurs  when  the  tumors  are 
in  a  position  to  block  the  urethra,  and  by  the  sloughing  off  or  de- 
tachment of  small  fragments,  which  may  or  may  not  be  incrusted. 
These  are  forced  into  the  urethra,  and  obstruct  the  outflow  of 
urine. 

Pain  in  one  form  or  another  is  almost  always  present.  It  may 
consist  of  a  simi:)le  uneasiness  in  the  hypogastric  region,  or  amount 
to  actual  pain.  It  may  have  its  seat  in  the  hypogastric  region  in  the 
perinseum,  or  more  rarely  at  the  end  of  the  urethra.  It  may  also  be 
felt  in  the  loins,  or  along  the  thigh  and  knee.  It  is  usually  more 
intense,  as  all  the  symptoms  are,  during  the  menstrual  flow.  This 
is  not  so  in  all  cases. 

Frequent  urination  and  vesical  tenesmus  are  as  a  rule  present. 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       801 

but  are  not  proportionate  to  the  size  of  the  tumor,  a  very  small  neo- 
plasm often  giving  rise  to  most  intense  spasm. 

Haemorrhage  is  by  no  means  infrequent,  and  in  some  cases  is 
very  severe  and  not  readily  checked  ;  in  others  it  is  slight,  sim])ly 
tinging  the  urine  or  imparting  to  it  a  smoky  appearance,  that  is 
characteristic  of  the  presence  of  a  small  amount  of  blood  or  blood- 
coloring  matter  in  acid  urine.  When  the  hsemorrhage  is  extensive, 
and  the  bladder  is  distended  by  the  fluid  or  clotted  blood,  retention 
of  urine  is  apt  to  occur,  and  sometimes  obstructive  suppression,  that 
may  lead  to  most  serious  results. 

Hsematuria  is  as  liable  to  occur  with  the  benign  as  with  the  ma- 
lignant growths,  and  consequently  is  of  little  value  in  differential 
diagnosis.  The  effects  of  prolonged  or  repeated  hf^emorrhage  upon 
the  constitution  are  often  most  serious,  and  the  patients  are  apt  to 
be  ansemic  and  also  cachectic  in  appearance.  I  have  had  one  case  in 
which  hgemorrhage  was  the  only  symptom  present. 

The  presence  of  the  foreign  body  in  the  organ  soon  gives  rise  to 
inflammation,  which  is  seriously  aggravated  if  retention  accompany 
it.  The  urine  is  then  found  loaded  with  mucus,  muco-purulent  or 
purulent  matter,  epithelial  scales,  tissue  shreds,  bits  of  tumor,  and 
the  triple  and  amorphous  phosphates. 

Intense  and  repeated  vesical  tenesmus  aggravates  the  inflamed 
condition  of  the  membrane,  and  after  a  time  leads  to  muscular  hyper- 
trophy and  increased  hemorrhage. 

In  these  cases,  as  in  cj^stitis  from  any  other  cause,  dilatation  of 
the  ureters,  with  a  traveling  upward  of  the  inflammation  and  destruc- 
tion of  the  kidney,  may  result.  This  dilatation  and  the  evil  after- 
results  are  more  apt  to  occur  if  the  neoplasm  be  of  sufficient  size  to 
obstruct  the  free  outflow  of  urine,  as  at  every  spasmodic  and  forcible 
contraction  of  the  hypertrophied  organ  some  urine  is  dammed  back 
in  the  ureters,  dilating  them  gradually.  When  the  ureteric  openings 
are  dilated,  so  that  urine  regurgitates  at  each  vesical  contraction, 
serious  lesions  result,  as  ureteritis,  pyonephrosis,  renal  abscess,  or,  if 
the  process  be  slow,  gradual  renal  atrophy,  uraemia,  and  finally 
death. 

The  general  system  may  or  may  not  suffer  severely  for  a  long 
time.  In  most  cases  it  does.  The  usual  train  of  symptoms,  such  as 
loss  of  sleep,  disorder  of  digestion,  sweating,  and  blood  contamina- 
tion are  developed  in  regular  sequence.  The  patients  become  thin, 
and  have  a  worn,  anxious  expression,  and,  as  I  have  already  said,  are 
apt  to  be  both  anaemic  and  cachectic. 

If  renal  troubles  complicate  this  affection,  casts,  renal  cells,  and 


862  DISEASES  OF  WOMEN". 

albumen  may  appear  in  the  urine.  In  renal  abscess-atropliy,  or  pyo- 
nephrosis, however,  the  urine  may  be  examined  for  weeks  without 
showing  any  renal  tissue,  casts,  or  epithelium,  there  being  simply  an 
abundance  of  pus. 

Diagnosis. — The  diagnosis  of  vesical  neoplasms  is  made  chiefly 
by  physical  signs.  The  methods  employed  in  their  investigation 
may  be  arranged  under  two  heads. 

Direct. — Bimanual  touch,  speculum,  endoscope,  curette,  catheter, 
palpation. 

Indirect. — Urine. 

Direct. — An  intelligent  employment  of  the  methods  classed  under 
the  first  head  is  all  that  is  necessary  to  make  a  clear  diagnosis  in 
some  cases.  The  bimanual  touch  will  reveal  the  presence  of  the 
tumor,  if  it  is  of  any  great  size,  and  also  its  size  and  fixation  in  one 
place.  This  fixed  position  is  of  much  importance  as  distinguishing 
a  neoplasm  from  other  foreign  bodies,  stone,  for  example,  which  is 
movable,  and  can  be  pushed  from  one  side  of  the  bladder  to  the 
other.  The  use  of  the  endoscope  will  show  at  once  the  appearance 
of  the  tumor,  if  it  is  favorably  located,  and  by  scraping  away  a  little 
with  the  curette  (through  the  speculum),  its  nature  may  be  discov- 
ered by  a  microscopical  examination. 

The  use  of  the  catheter  or  finger  in  the  bladder,  or  one  in  the 
bladder  and  the  other  in  the  vagina,  may  be  resorted  to  in  cases 
where  the  diagnosis  is  difficult.  But  these  are  extremely  painful 
manipulations,  are  not  free  from  danger,  and,  consequently,  should 
not  be  resorted  to  unless  there  is  failure  by  other  means. 

Indirect. — An  examination  of  the  urine  in  these  cases  will  lead 
to  the  suspicion  of  the  presence  of  some  neoplasm  in  the  bladder, 
from  the  occurrence  of  tissue  shreds  and  bits  of  the  tumor  in  this 
fluid.  A  piece  of  tumor  will  sometimes  become  detached  and  be 
expelled  with  the  urine,  and  by  careful  searching  it  may  be  found. 
This  can  be  placed  under  the  microscope,  and  thus  the  examiner 
may  be  able  to  tell  exactly  what  kind  of  a  growth  exists. 

Prognosis. — With  our  present  means  for  exploring  and  operat- 
ing upon  the  inside  of  the  female  bladder,  the  prognosis  of  benign 
neoplasms  is  very  good,  if  the  operation  for  removal  be  performed 
early  enough  in  the  disease.  Operation,  however,  at  any  time  gives 
promise  of  good  result. 

There  is  danger  of  relapse,  as  we  learn  from  the  cases  of  Simon, 
Hutchinson,  and  others.  If  the  operation  be  carefully  done,  even 
incontinence  of  urine  may  be  avoided,  and  com])lete,  and  permanent 
recovery  follow.     Without  operation  patients  have  lived  as  long  as 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.         863 

nineteen  years,  in  some  cases  suffering  but  little ;  and  it  may  be 
well  to  say  that  not  all  of  these  cases  are  accompanied  by  cystitis,  a 
little  pus  and  blood  in  the  urine  at  intervals,  with  occasional  frag- 
ments of  tumor,  being  all  that  is  found. 

Causation. — The  causes  of  these  neoplasms  are  very  obscure  ;  in- 
deed, no  definite  facts  can  be  adduced  in  favor  of  any  of  the  causes 
given  by  the  various  authors.  Some  speak  of  them  as  due  to  the 
irritation  of  calculi,  calculous  fragments,  and  incrustations.  These, 
however,  may  be  readily  secondary  to  and  produced  by  the  neoplasm, 
being  the  effect  rather  than  the  cause.  Moreover,  it  is  known  that 
while  persons  carrying  foreign  bodies  of  various  kinds  in  the  blad- 
der for  a  length  of  time  are  very  apt  to  have  cystitis,  neoplasms  are 
seldom  found,  and  are  very  rare  under  any  circumstances. 

Some  authors  look — with  a  show  of  reason,  I  think — to  the  irri- 
tation from  blood  transudations  into  the  bladder-walls  as  a  cause. 
This  is  borne  out  by  two  well-authenticated  cases  occurring  one  in 
the  practice  of  Hutchinson,  of  England,  the  other  in  that  of  Winckel, 
of  Germany.  The  etiology  of  these  neoplasms  needs  further  care- 
ful study  before  any  cause  or  causes  can  be  pronounced  upon  with 
certainty.  The  free  and  intelligent  use  of  the  modern  means  of 
physical  exploration  in  all  affections  of  the  female  bladder  will  in  a 
few  years  throw  much  light  upon  this  subject. 

Treatment. — There  is  really  but  one  form  of  treatment  for  these 
benign  neoplasms,  viz.,  removal.  The  treatment  of  ulcerations  and 
small  neoplasms  of  the  urethra  and  bladder  has  been  completely 
revolutionized  within  the  past  five  or  six  years.  The  changes  that 
have  been  made  are,  in  my  opinion,  all  for  the  better.  I  now  use 
the  galvano-cautery,  instead  of  strong  caustics  that  were  employed 
in  days  gone  by.  Strong  caustic  injections  for  ulceration  of  the 
bladder  and  nrethra,  and  similar  applications  to  new  growths,  were 
always  unsatisfactory.  They  caused  no  end  of  suffering  and  often 
failed  to  relieve  or  cure,  and,  when  successful  in  arresting  disease, 
scar  tissue  followed  that  was  troublesome — many  times  extremely  so. 
The  great  objection  to  the  use  of  caustics  for  the  purpose  of  de- 
stroying diseased  tissue  is  that  the  effect  can  not  be  controlled.  If 
one  destroys  all  of  the  diseased  tissue  some  of  the  normal  tissue  is 
sure  to  be  scorched,  and  if  one  guards  against  the  latter  he  fails  in 
the  former. 

The  advantages  of  the  cautery  in  treating  ulcers  and  neoplasms 
are  that  its  action  can  be  thoroughly  controlled.  Morbid  growths 
and  diseased  or  ulcerating  tissue  can  be  completely  destroyed,  while 
the  normal  tissues  are  left  uninjured.     The  line  of  demarkation  be- 


8g4  DISEASES  OF   WOMEN. 

tween  the  charred  and  normal  tissue  can  be  sharply  defined  by  the 
operator,  and  the  healing  process  goes  on  rapidly  and  without  pain. 
By  the  time  the  eschar  separates  the  parts  beneath  have  become  suf- 
ficiently repaired  to  withstand  the  contact  of  urine,  and  so  the  re- 
currence of  inflammation  or  ulceration  is  guarded  against.  When 
the  cautery  can  be  properly  used  the  results  are  very  gratifying. 
There  was  much  trouble  in  getting  at  new  growths,  ulcers,  and  fis- 
sures at  the  neck  of  the  bladder,  especially  until  Kelly  introduced 
his  method  ;  but  after  that  I  found  the  cautery  could  be  used  at  any 
point  that  could  be  brought  into  the  field  of  the  endoscope.  In  treat- 
ing neoplasms  a  fine  cautery  point  is  used,  touching  repeatedly  the 
parts  until  all  new  or  diseased  tissue  is  destroyed.  For  ulcers  a  flat 
point  is  used,  passing  it  over  the  diseased  surface  in  about  the  same 
way  that  one  would  apply  a  solution  with  a  pencil.  Of  coui-se,  small 
neoplasms  and  ulcers  only  can  be  treated  in  this  way.  Since  adopt- 
ing this  plan  of  treatment  I  have  been  able  to  cure  cases  of  cystitis 
with  ulceration  and  vascular  proliferations  that  formerly  baflfled  me 
completely.  Such  cases  conld  only  be  relieved  by  drainage  through 
a  vesico-vaginal  fistula,  which  Emmet  taught  us  to  establish  in  bad 
cases.  A  full  description  of  the  apparatus  I  employ  is  given  by  Mr. 
Pignolet  on  page  429. 

The  treatment  of  large  tumors  of  the  bladder  has  hitherto  con- 
sisted in  doing  suprapubic  cystotomy  and  removing  the  neoplasms 
with  the  scissors  or  curette,  controlling  the  Imemorrhage  by  pressure 
or  styptics,  and  then  draining.  Tlie  results  have  been  very  unsatis- 
factory. Some  patients  did  not  recover,  and  those  who  did  required 
a  long  time  to  do  so. 

There  certainly  was  room  for  improvement  in  this,  and  I  have 
tried  to  do  better  by  adopting  a  new  way,  which  I  desire  to  submit 
for  your  judgment,  and  that  is  compression  and  desiccation  with 
electric  heat.  The  process  consists  in  seizing  the  tissues  to  be 
treated — the  base  of  a  vascular  tumor  of  the  bladder,  for  example — 
in  a  clamp  or  forceps,  and  then  heating  the  inner  side  of  the  blade 
of  the  forceps  with  electricity  to  a  degree  sufficient  to  desiccate  the 
tissues  under  pressure,  thus  arresting  all  haemorrhage  and  reducing 
the  stump  to  the  smallest  ])ossible  size. 

The  after-treatment  consists  in  washing  out  the  organ  thoroughly 
yet  carefully  with  warm  water  to  which  may  be  added  salicylic  acid 
(1  part  to  00).  The  pain  may  he  controlled  by  opium,  either  by  the 
mouth  or  rectum.  The  urine  should  be  kept  slightly  alkaline,  and 
under  no  circumstances  allowed  to  remain  in  the  bladder  long  enough 
to  decompose  and  irritate  or  overdistend  it. 


NON-INFLAMMATORY   DISEASES  OF  THE   BLADDER.         865 

If  the  tumor  is  too  large  to  admit  of  removal  jper  urethrann  Si- 
mon's operation  should  be  resorted  to.  Also  in  cases  where  the  tumor 
is  so  situated  as  to  be  beyond  the  operator's  reach  through  the  ure- 
thra. I  have  already  fully  described  this  operation.  A  T-incision 
is  made  into  the  anterior  vaginal  wall,  the  bladder  opened,  inverted 
through  the  opening,  and  the  tumor  is  thus  brought  into  easy  posi- 
tion for  any  operative  procedure.  When  removed,  its  base  may  be 
cauterized,  and  the  bladder  replaced.  When  the  surface  has  entirely 
healed,  the  wound  in  the  vesico-vaginal  septum  may  be  closed. 
Union  soon  takes  place  in  most  of  these  cases,  if  not  interfered 
with.  The  after  treatment  should  be  the  same  as  when  the  tumor  is 
removed  through  the  urethra. 

I  need  hardly  say  that  when  the  general  system  is  below  2Dar,  it 
should  be  attended  to. 

Polypus  of  the  Bladder.  — Dr.  Godson  showed  a  polypus  which  he 
had  recently  removed  from  a  woman  aged  sixty,  who  was  under  his 
care  in  St.  Bartholomew's  Hospital.  He  first  saw  her  a  year  ago, 
when  she  complained  of  bleeding  from  the  vagina.  The  uterus  and 
vagina  were  found  healthy,  there  had  been  no  recurrence  of  the 
hsemorrhage  until  a  week  since  when  the  patient  again  presented 
herself.  On  examination  a  tumor  the  size  of  a  walnut  was  found 
at  the  orifice  of  the  vagina.  It  had  at  first  sight  the  aspect  of  a 
firm  fibrinous  clot ;  it  was  discovered,  however,  to  protrude  from 
the  urethra,  and  to  be  connected  by  a  narrow  pedicle  with  the  fun- 
dus of  the  bladder,  which  organ  it  partially  inverted.  Dr.  Godson 
applied  a  catgut  ligature,  and  separated  it  with  scissors.  A  micro- 
scopical examination  showed  it  to  consist  of  fibro-cellular  tissue, 
with  a  few  muscular  fibers  covered  over  with  mucous  membrane. 
Such  polypi  are  of  extreme  rarity,  and  it  was  fortunate  that  the 
subject  of  it  was  a  woman. — {Obstetrical  Journal^  AjjpU  1879, 
p.  28). 

Excision  of  Papilloma  of  Bladder. — M.  C,  aged  thirty-four,  was 
admitted  to  the  St.  Mary's  Hospital,  under  the  care  of  Mr.  Norton, 
suffering  from  the  effect  of  long-continned  haemorrhage  of  the 
bladder.  On  examination  2)er  urethram,  a  tumor  one  inch  square, 
coated  with  phosphatic  calcuhis,  but  not  much  raised  above  the 
mucous  membrane,  was  discovered  occupying  the  trigone  about  half 
an  inch  from  the  sphincter.  It  was  evident  that  the  tumor  must  be 
removed,  and  the  patient  submitted  to  the  risks  attendant  upon  a 
severe  operation,  or  she  must  be  left  to  endure  the  tortures  brought 
about  by  the  contractions  of  the  bladder  upon  the  growth  after 
micturition,  and  with  the  certainty  of  an  early  death  from  hsemor- 


866  DISEASES  OF  WOMEN. 

rhage  or  from  blood-poisoning.  It  was  impossible  to  remove  the 
growth  through  the  urethra,  and  it  was  decided  to  cut  the  mass  away 
by  opening  the  vagina.  It  was  considered  that  the  growth  could 
not  be  cleared  without  cutting  through  the  urethra,  and  the  opera- 
tion was  performed  as  follows :  The  spring-scissors  were  inserted, 
one  blade  into  the  bladder  nearly  up  to  the  tumor  and  the  other 
into  the  vagina,  and  closed ;  the  front  wall  of  the  vagina  was  then 
incised  centrally  to  within  half  an  inch  of  the  uterus,  and  the  vaginal 
wall,  which  was  found  not  to  be  incorporated  with  the  growth  was 
dissected  from  the  bladder ;  the  growth  was  then  seized  with  the 
vulsellum  forceps,  and  drawn  forward,  and  was  then  excised  by  the 
scissors  and  removed.  Bleeding  was  averted  by  the  actual  cautery, 
and  the  lateral  flaps  of  the  vagina  approximated  by  sutures.  To 
prevent  further  haemorrhage  a  catheter  was  inserted,  and  the  bladder 
compressed  by  plugging  the  vagina ;  no  haemorrhage  of  importance 
took  place.  The  temperature  remained  below  normal,  and  the 
pulse  rose  to  120.  Severe  vomiting  persisted  until  the  tenth  day 
after  the  operation,  when  she  was  considered  out  of  danger.  On 
the  twelfth  day,  when  apparently  in  health,  she  vomited,  and  shortly 
afterward  fell  asleep,  in  which  sleep  she  died  from  syncope.  At 
the  autopsy  the  wound  was  green,  and  sloughing  upon  the  surface, 
but  healthy  immediately  beneath.  No  peritonitis  or  cellulitis  was 
present,  or  any  thrombosis  of  vesical,  pelvic,  or  iliac  veins.  A 
microscopical  examination  showed  the  tumor  to  be  a  papilloma. 
Since  writing  this  case  Mr.  Norton  had  operated  upon  a  second  case 
of  tumor  of  the  bladder,  which  had  completely  recovered  from  the 
effects  of  the  operation. — The  Medical  Press  and  Circular,  May 
i^,  1870 ;  and  Medical  Record,  Jidy  26,  1879,  pp  82  and  83. 

Tubercle  of  the  Bladder. — Tubercle  of  the  female  bladder  is  a 
comparatively  rare  affection.  Winckel,  of  Germany,  in  2,505 
autopsies,  found  it  but  four  times.  Though  not  often  existing  as  an 
accompaniment  of  pulmonary  tuberculosis,  it  does  not  occur  alone, 
but  is  usually  accompanied  by  similar  deposits  in  the  intestines, 
kidneys,  liver,  and  elsewhere.  It  is  usually  found  in  early  life, 
though  cases  have  been  recorded  where  it  occurred  as  late  as  the 
sixty-fifth  year. 

The  favorite  site  for  its  first  appearance  is  at  the  vesical  neck,  or 
about  the  meatus  urinarius,  these  places  being  rich  in  minute  glands 
and  follicles.  The  deposits  appear  as  minute  white  or  yellowish 
white  points  on  a  red,  indurated  base.  After  a  time,  owing  to  their 
coalescing  and  breaking  down,  large  spots  of  ulceration  result. 

With  these  deposits  in  the  bladder  there  are  very  apt  to  be  simi- 


NON-INFLAMMATORY  DISEASES  OP  THE   BLADDER.         867 

lar  deposits  in  the  kidneys  and  ureters,  giving  rise  to  destrnction 
of  the  former  and  tuberciTlar  pyehtis  in  the  latter. 

Symptomatology. — The  symptoms  are  at  iirst  those  of  irrita- 
tion, and  later  of  true  cystitis,  with  ulceration,  induration,  and 
hypertrophy. 

Diagnosis. — The  diagnosis  may  be  made  by  means  of  the  endo- 
scope, if  there  is  opportunity  to  make  early  and  repeated  examina- 
tions. If  by  chance  the  deposits  are  located  at  the  neck  of  the 
bladder,  where  they  can  be  seen  and  watched  going  on  to  ulcera- 
tion, the  diagnosis  is  not  impossible.  The  history  of  the  case 
and  the  presence  of  the  tubercular  diathesis  will  also  aid  in  the 
final  conclusions.  The  urine  examined  by  the  microscope  is  found 
to  contain  a  granular  matter  mixed  with  the  pus  of  cystitis  which  is 
sooner  or  later  produced.  In  case  the  microscopist  is  fortunate  iu 
finding  the  bacillus  tuberculosis  the  diagnosis  is  sure. 

Prognosis. — The  prognosis  is  bad,  as  there  usually  exists  serious 
trouble  of  the  same  nature  elsewhere,  and  as  local  treatment  accom- 
plishes very  little,  the  end  comes  much  sooner  if  the  kidneys  and 
ureters  are  involved  in  the  disease. 

Treatment. — Local  treatment  is  out  of  the  question,  except  such 
as  may  allay  the  irritation  or  inflammation  to  a  certain  extent,  and 
prevent  undue  pain  and  spasm.  This  is  not  readily  done.  Daily 
cleansing  of  the  viscus  with  warm  water;  opium,  and  belladonna 
suppositories,  or  enemata  of  atropine,  are  the  best  methods  of  treat- 
ment. 

Warmth,  attention  to  diet,  general  tonics,  cod-liver  oil,  and  the 
various  remedies  used  in  phthisis  pulmonalis  should  be  advised. 

Malignant  Growths. — These  are  not  common,  although  occurring 
more  often  than  the  benign  growths.  They  are  usually  secondary, 
and  may  be  of  different  varieties,  as  sarcoma,  scirrhus,  encephaloid, 
epithelial,  villous,  and  even  colloid  cancer.  Sarcoma,  scirrhus, 
colloid,  and  epithelial  are  very  rare ;  encephaloid  and  villous  are 
more  common. 

Symptomatology. — The  symptoms  are  the  same  as  those  of  the 
benign  tumors,  differing  only  in  the  greater  extent  and  severity  of 
the  pain,  and,  as  a  rule,  less  haemorrhage.  The  condition  of  the  gen- 
eral system  is  usually  low,  the  patient  soon  becoming  feeble  and 
cachectic.  Cancerous  deposits  in  the  kidney  and  extension  of  the 
inflammation  up  the  ureters,  may  produce  renal  destruction  and 
consequent  uraemia. 

Diagnosis. — The  only  means  of  making  an  absolute  diagnosis  is. 
by  using  the  endoscope,  and  removing  a  bit  of  the  tumor  with 


8fi8  DISEASES   OF   WOMEN. 

the  curette,  and  submitting  it  to  a  microscopical  examination. 
Sarcoma  and  scirrhus  may  exist  either  as  distinct  tumors  or  as 
diffused  indurations.  The  encephaloid  variety  usually  grows  rap- 
idly, and  is  very  soft,  and  easily  broken  down.  I  have  already  said 
that  cancer  of  neighboring  organs  may  open  into  the  bladder  and 
produce  most  serious  results,  sooner  or  later  involving  the  bladder- 
tissue  in  the  destructive  process.  In  any  case,  adhesion  to  the 
neighboring  organs  takes  place,  and  the  disease  is  liable  to  extend. 
Thrombosis  of  the  veins  of  the  vesical  neck  is  apt  to  occur  and  lead 
to  embolus  elsewhere.     Peritonitis  is  a  frequent  accomjDaniment. 

The  favorite  seat  of  cancer,  especially  of  the  villous  form,  is  at 
the  trigone.  Some  authors  deny  the  existence  of  villous  cancer, 
saying  that  it  is  simply  a  luxuriant  growth  of  vesical  papilloma, 
and  base  their  opinion  upon  the  nature  of  its  structure  and  certain 
facts  in  its  clinical  history.  "  They  never  lead  to  secondary  can- 
cerous deposits  elsewhere.  They  do  not  spontaneously  ulcerate. 
The  lymphatic  glands  are  not  implicated.  There  is  no  characteristic 
cachexia.  When  they  kill,  death  seems  due  purely  to  loss  of  blood 
and  exhaustion  from  pain." —  Va7i  Bnren  and  Keyes^  ]}•  ^^'^• 

Most  German  authors  claim  that  this  growth  is  malignant,  and 
think  that  in  drawing  deductions,  such  as  I  have  given  above,  the 
observers  saw  only  cases  of  simple  non-malignant  papilloma. 

Causation. — Nothing  is  knowm  about  the  causes  of  malignant 
disease  of  the  bladder,  except  that  which  is  known  about  malignant 
disease  elsewhere,  consequently,  that  subject  need  not  be  discussed 
here. 

Treatment. — If  the  disease  is  not  too  far  advanced,  extirpation 
or  breaking  down  of  the  tumor  may  be  advisable,  but  except  in  the 
case  of  epithelioma,  and  the  so-called  villous  cancer,  but  little  good 
is  to  be  hoped  for. 

When  removal  is  not  advisable,  we  must  look  to  narcotics  and 
tonics  to  prolong  the  patient's  life  and  relieve  the  intense  pain  and 
tenesmus. 

If  the  tumor  is  generally  distributed  throughout  the  bladder,  or 
has  its  origin  in  a  neighboring  organ,  extirpation  is  out  of  the 
question. 

Sarcomatous  Tumor  of  the  Bladder. — Dr.  L.  A.  Stimson,  at  a  society 
meeting,  exhibited  a  tumor  of  the  bladder  removed  from  a  gentleman 
sixty-three  years  of  age.  When  admitted  to  the  Presbyterian  Hos- 
pital in  the  eai'ly  part  of  October,  the  patient  complained  of  frequent 
and  painful  passage  of  bloody  urine.  His  lirst  attack  occured  in  the 
eariy  part  of  July,  and  two  or  three  weeks  after  a  fall  from  a  buggy. 


NON-INFLAMMATORY  DISEASES  OF   THE  BLADDER.         8^)9 

For  the  previous  four  years  he  gave  a  history  of  attacks  of  so-called 
bilious  colic,  which  in  connection  with  his  bladder  trouble  gave  rise 
to  the  suspicion,  in  the  mind  of  Dr.  Stimson,  of  renal  colic,  and  the 
possible  existence  of  vesical  calculus.  After  unavailing  efforts  to 
reduce  the  irritability  of  the  bladder  the  patient  was  sounded  for 
stone  with  negative  results.  A  subsequent  examination  was  also  of 
a  negative  character.  The  use  of  the  searcher  was  followed  each 
time  by  blood  in  the  urine  for  two  or  three  days  consecutively. 
'Exa.miusbtion  per  rectum  revealed  enlargement  of  the  prostate,  and 
fulness  and  doughiness  about  the  bladder,  which  condition  was  sup- 
posed to  be  due  to  cystitis.  The  existence  of  a  tumor  was  suspected, 
but  the  suspicion  could  not  be  confirmed,  inasmuch  as  the  condition 
of  the  patient  forbade  bimanual  exploration.  Ruling  out  the  prob- 
ability of  the  existence  of  a  tumor  of  the  bladder,  pyelitis  was 
thought  of  as  a  cause  for  his  trouble.  The  patient  died  rather 
suddenly  without  a  positive  diagnosis  having  been  made.  At  the 
autopsy,  and  before  the  body  was  opened,  bimanual  palpation  was 
performed,  and  the  existence  of  a  tumor  was  made  out.  On  open- 
ing the  bladder  the  morbid  growth,  which  proved  to  be  a  sarcoma, 
three  inches  in  diameter,  was  attached  by  a  pedicle  as  thick  as  the 
finger  to  the  posterior  surface  of  the  bladder,  about  four  inches 
above  the  neck  of  the  organ. 


HYPERPLASIA. 

Hyperplasia  of  the  bladder  may  be  partial  or  total ;  may  be  con- 
fined to  the  muscular,  mucous,  or  connective  tissue.  In  using  the 
term  hyperplasia  reference  is  usually  made  to  an  increased  thickness 
of  the  muscular  walls  alone.  There  usually  coexists  with  this  con- 
dition (which  is  partly  hypertrophy,  partly  hyperplasia)  increase  in 
thickness  of  the  various  other  structui'es  of  the  organ.  This  may  or 
may  not  be  the  case,  and  when  existing  it  is  more  hyperplasia  than 
hypertrophy.  The  terms  partial  and  total  have  been  used  to  convey 
the  idea  of  hypertrophy  of  a  part  or  parts  of  the  muscular  tissue,  and 
do  not  usually  refer  to  the  number  of  coats  involved.  The  truth  is, 
however,  that  one  part  of  the  muscular  tissue  of  the  organ  seldom 
becomes  hypertrophied  to  any  extent  without  involving  the  other 
parts ;  the  increase  in  one  part  simply  being  greater  than  in  another. 

This  affection  is  much  less  frequent  in  the  female  than  in  the 
male,  owing  to  her  exemption  from  the  more  common  causes  of  it. 
Any  obstruction  to  the  outflow  of  urine,  as  tumors  of  the  urethra 
or  bladder,   partly  or  wholly  blocking  the  passage;  cystocele,  by 


8Y0  DISEASES   OF  WOMEN. 

preventing  complete  evacuation  ;  inflammatory  or  nervous  troubles, 
causing  unusually  active  muscular  contraction,  continuing  for  some 
time  ;  all  these  may  produce  muscular  hyperplasia.  Inflammation 
of  the  mucous  membrane  is  almost  always  present ;  sooner  or  later, 
that  membrane  becomes  to  a  certain  extent  thickened,  and  may  go 
as  far  as  the  production  of  tufty,  polypoid  hyperplasia.  Van  Buren 
and  Keyes  state  that  Civiale  mentions  hypertrophy,  chiefly  of  the 
anterior  vesical  wall,  due  to  chronic  inflammation  or  tubercular  in- 
filtration— evidently  not  simple  hypertropliy. 

As  the  production  of  hypertrophy  is  almost  always  due  to  some 
obstruction  to  the  outflow  of  the  urine,  dilatation  after  a  time  oc- 
curs, producing  eccentric  hyperplasia.  When  dilatation  does  not 
occur,  but  Inperplasia  alone,  the  condition  is  produced  which  is 
known  as  concentric  hy|)erplasia.  In  these  cases  of  muscular  hyper- 
trophy in  which  great  force  is  required  to  expel  the  urine,  pouches 
are  sometimes  formed,  usually  at  the  inferior  fundus,  caused  by  the 
pushing  of  the  mucous  membrane  between  the  enlarged  muscular 
fibers.  These  diverticula  are  comparatively  rare  in  the  female.  A 
sagging  or  dislocation  of  the  entire  posterior  inferior  bladder-wall 
need  not  be  discussed  here,  as  it  has  been  already  disposed  of. 

Symptomatology. — In  concentric  hyperplasia  there  is  usually  vesi- 
cal spasm,  some  pain,  and  forcible  ejection  of  urine.  A  certain 
amount  of  cystitis  almost  always  accompanies  this  affection,  and 
surely  aggravates  the  original  disorder,  by  which  it  is  itself  further 
aggravated.  In  the  eccentric  form  the  symptoms  are  almost  the 
same,  there  being  sometimes  superadded  those  of  overdistention. 

Diagiiosis. — This  is  readily  made  by  introducing  the  finger  into 
the  vagina  and  the  sound  into  the  bladder,  by  which  means  the  ca- 
pacity of  the  organ  can  l)e  measured  and  the  thickness  of  its  walls 
ascertained.  It  is  not  unusual  in  the  concentric  form  for  the  sound 
to  be  forcibly  expelled  from  the  bladder  by  a  sudden  contraction  of 
that  organ.  The  capacity  of  the  viscus  can  be  further  measured  by 
noting  the  amount  of  urine  passed  at  each  micturition,  or  by  inject- 
ing into  it  some  bland  solution,  such  as  salt  and  lukewarm  water. 

Treatment. — The  treatment  must  be  directed  to  the  removal  of 
the  cause  when  that  is  possible.  If  due  to  stricture  of  the  urethra 
or  the  presence  of  tumors,  their  removal  is  to  be  considered;  if  to 
cystocele,  replacement,  and  retention  in  place  by  a  proper  pessary, 
and  other  measures  of  which  I  have  spoken  fully  in  a  previous 
chapter,  must  be  adopted. 

When  existing  in  the  eccentric  form  an  abdominal  belt,  cold 
baths,  cold  douches  to  the  hips,  astringent  injections  into  the  blad- 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER,         871 

der,  and  electricity,  should  be  tried,  having  first,  where  possible, 
removed  the  cause,  and  palHated  or  cured  the  aggravating  compHca- 
tions.  Daily  catheterization,  in  cases  of  obstruction  to  the  outflow 
of  urine,  or  where,  without  obstruction  there  is  liability  to  over- 
distention,  is  of  great  importance,  and  should  be  practiced. 


ATROPHY. 

So  far  as  I  know  this  is  not  a  common  disease.  Its  recognition 
during  life  being  by  no  means  easy,  and  but  little  attention  being 
paid  to  the  bladder  in  autopsies,  very  little  knowledge  of  its  fre- 
quency is  had.  I  am  inclined  to  believe,  however,  that  it  exists 
oftener  than  is  commonly  supposed.  Its  causes  may  be  ranged 
under  two  heads,  viz.,  constitutional  and  local. 

Constitutional. — In  most  women  from  fifty  years  of  age  upward 
a  degenerative  change  takes  place  in  the  bladder,  as  in  the  other 
pelvic  organs,  and  this  is  a  perfectly  natural  process.  In  this  con- 
dition the  several  coats  are  found  proportionally  changed,  the  three 
sometimes  forming  a  wall  not  much  thicker  than  fine  writing-paper. 
This,  however,  is  extreme  and  uncommon.  The  process  causing 
atrophy  is  one  of  fatty  and  granular  degeneration,  and  often  at  this 
age  the  epithelial  cells  of  the  bladder  found  in  the  urine  are  fatty 
and  granular,  as  is  also  the  case  in  both  the  vesical  and  vaginal  epi- 
thelium of  some  women  just  after  parturition. 

Walls  thus  thinned  by  the  degenerative  changes  of  age  are  of 
course  much  more  Hable  to  be  still  further  altered  by  various  causes, 
such  as  paralysis  or  overdistention.  Winckel  attributes  the  cysto- 
cele  of  aged  women  to  atrophy  of  the  bladder  walls,  and  the  result- 
ing retention  of  urine. 

In  soft,  flabby  and  debilitated  women,  and  also  in  men,  an  atro- 
phied condition  of  the  bladder- walls  often  exists,  and  in  ay  lead  to 
rupture.  "  Bonnet,  Hauf,  and  Hunter  (quoted  by  Pitha),  give  ex- 
amples of  sudden  rupture  of  the  bladder  in  young  persons  from 
this  cause  (atrophy).  Civiale  gives  the  caution  of  avoiding  pressure 
on  the  bladder- walls  during  catheterization,  for  fear  of  perforation." 
—  Van  Btiren  and  Keyes. 

Local  Causes. — Extreme  distention  of  the  bladder,  leading  to 
temporary  or  permanent  paralysis,  or  paralysis  with  resulting  over- 
distention,  may  lead  to  fatty  degeneration  and  atrophy,  as  well  as 
inflammatory  trouble.  Interrupted  nutrition,  due  to  shutting  off 
the  circulation,  is  the  usual  method  of  causation.  Nutritive  changes 
may  also  be  due  to  lack  of,  or  to  perverted,  innervation  caused  by 


872  DISEASES  OF  WOMEN. 

disease  or  injuries  of  the  spinal  cord.  "When  atrophy  occurs  in 
women  under  fifty  years  of  age,  who  are  in  otherwise  good  heahh, 
and  of  good  constitution,  I  beheve  that  it  is  due  to  habitual  over- 
distention  of  the  bladder  from  retention  of  urine. 

Treatment — Daily  use  of  the  catheter,  strychnia  in  pretty  full 
doses,  electricity,  building  up  of  the  general  system,  and  gentle 
washing  out  of  the  organ  with  warm  medicated  solutions,  may  be 
tried.     But  little  can  be  clone  when  the  defeneration  is  due  to  age. 

Atrophy  of  the  Bladder  from  the  Habit  of  retaining  the  Urine  for 
a  Long  Time. — The  lady  was  thirty-three  years  of  age,  large,  and 
well  developed,  except  that  her  heart  and  arteries  were  rather  small. 
Her  uterus  was  also  undersized.  She  began  to  menstruate  at  lifteen 
years  of  age,  and  her  menses  were  irregular  in  recurrence  and  dura- 
tion, and  always  attended  with  pain.  Early  in  life  she  became  a 
school-teacher,  and  had  followed  that  profession  up  to  the  time  that 
I  saw  her.  She  fell  into  the  habit  of  retaining  her  urine  for  long 
periods,  and  for  several  years  urinated  only  twice  in  each  twenty- 
four  hours.  For  some  time  she  had  noticed  a  growing  difficulty  in 
emptying  her  bladder,  and  five  months  before  consulting  me  she 
found  that  she  had  lost  the  power  of  urinating  altogether.  Her 
physician  used  the  catheter  regularly  for  a  time,  and  then  taught 
her  to  use  it  herself.  Under  this  treatment,  with  tonics  and  seda- 
tives, she  gradually  regained  a  partial  control  of  her  bladder;  but 
with  it  came  an  irritable  condition  of  that  organ  and  the  urethi-a, 
which  caused  an  almost  constant  desire  to  urinate. 

When  I  examined  her  I  found  slight  prolapsus  of  the  base  of  the 
bladder,  and,  by  passing  a  sound  into  it,  and  a  finger  in  the  vagina, 
I  found  the  posterior  bladder-wall  quite  thin.  There  were  also  in- 
dications of  a  slight  catarrh  of  the  organ,  doubtless  brought  on  by 
the  continued  overdistention  and  prolonged  use  of  the  catheter.  She 
told  me  that  she  had  to  make  strong  efforts  to  pass  urine,  and  that 
it  came  away  in  interrupted  jets. 

My  impression  of  this  case  is,  that  her  constant  neglect  of  the 
bladder  function  caused  overdistention,  which  led  to  atrophy  and 
further  distention.  The  use  of  the  catheter  permitted  the  organ  to 
partially  regain  its  muscular  power,  and  also  excited  some  catarrii. 
Passing  the  urine  in  spurts  or  jets  was  due,  I  presume,  to  the  volun- 
tary muscular  efforts. 


CHAPTER  XLYIII. 

PATENCY    OF    GARTNER's    DUCT. DISEASES    OF    THE    URETHRA    AND 

URETHRAL    GLANDS. 

It  is  now  generally  conceded  that  Gartner's  duct  may  remain 
patent  after  birth.  This  condition  must  be  very  rare,  but  its  rarity 
makes  it  very  difficult  of  recognition  when  it  does  occur.  The  fol- 
lowing case  is  illustrative  of  this  anomaly,  and  is  given  in  detail 
with  the  liope  that  it  may  be  of  service  to  some  practitioner  in  arriv- 
ine  at  a  diagnosis.  "With  this  in  mind,  other  cases  that  have  been 
regarded  as  suffering  from  incurable  "  incontinence  of  urine  "  may 
be  permanently  cured. 

ILLUSTRATIVE   CASE   OF   PATENCY    OF    GARTNEr's    DUCT. 

The  patient  was  nearly  fifteen  years  of  age,  very  large,  well  de- 
veloped, and  in  perfect  health  of  body  and  mind,  but  all  her  life 
had  been  greatly  annoyed  by  a  constant  watery  discharge  from  the 
urethra.  The  exact  amount  of  the  discharge  could  not  be  estimated. 
That  it  was  considerable  may  be  inferred  from  the  fact  that  it  kept 
her  underclothing  wet  all  day,  and  saturated  a  protecting  napkin 
at  night. 

She  retained  her  urine  the  normal  length  of  time ;  urinated 
freely  and  without  pain  or  discomfort.  The  discharge  from  the 
urethra  was  not  modified  in  quantity  by  the  erect  or  recumbent 
position,  nor  by  the  empty  or  distended  condition  of  the  bladder. 
The  most  careful  examination  of  all  the  pelvic  organs  revealed  noth- 
ing abnormal,  excepting  a  slight  ridge  or  fold  of  mucous  membrane 
in  the  vagina  on  the  right  side  anteriorly.  This  elevation  or  ridge 
ran  from  the  upper  third  of  the  urethra  upward  to  the  junction  of 
the  vagina  and  cervix  uteri. 

Its  presence  attracted  my  attention,  but  did  not  impress  me  as 
anything  of  importance.     The  urethra  was  rather  short,  but  normal 

873 


874  DISEASES  OF  WOMEN. 

in  every  way,  and  the  urethral  ducts  also ;  and  I  presumed  that 
the  muscular  tissue  might  be  defective  at  the  neck  of  the  blad- 
der, and  hence  there  might  be  a  slight  incontinence.  This,  how- 
ever, was  not  sustained  by  the  clinical  history.  The  patient  was 
admitted  to  my  sanatorium,  where  I  was  able  to  investigate  the  case 
thoroughly. 

Under  the  observations  of  a  skilled  nurse  it  was  determined  that 
the  discharge  came  from  the  urethra  and  that  there  was  no  leaking 
from  the  bladder.  I  then  suspected  that  there  might  be  an  irregular 
implantation  of  one  ureter.  A  cystoscopic  examination  was  made, 
and  both  ureters  were  found  in  their  normal  position  and  were  per- 
forming their  function  all  right.  Double  bladder  was  thought  of, 
with  a  communication  between  the  one  into  which  the  ureters  en- 
tered and  the  other.  This  idea  was  abandoned,  because  no  known 
derangement  of  development  could  eventuate  in  such  a  malforma- 
tion. Being  unal)le  to  find  any  cause  for  this  discharge  in  any  lesion 
of  the  bladder,  I  examined  the  fluid  and  found  that  it  contained  a 
very  few  epithelial  cells  and  a  trace  of  albumin,  but  none  of  the  con- 
stituents of  urine.  It  was  not  urine  at  all,  as  had  been  supposed. 
A  number  of  endoscopic  examinations  of  the  urethra  were  made  at 
different  times  in  the  hope  of  finding  the  opening  into  the  urethra, 
with  most  discouraging  results.  Finally,  on  one  occasion,  after 
making  a  prolonged  exploration  (M'ith  a  fine  probe  used  through 
the  endoscope)  of  the  upper  part,  I  withdrew  the  instrument  a  very 
little  way  and  observed  a  jet,  as  fine  as  a  hair,  of  clear  fluid.  The 
discharge  had  been  stopped  by  the  pressure  of  the  endoscope,  and 
on  the  removal  of  the  pressure  the  discharge  came  with  force 
enough  to  make  it  visible.  1  then  tried  to  introduce  a  probe  into 
the  opening,  but  that  was  impossible,  owing  to  its  small  size.  The 
opening,  I  observed,  was  at  the  place  where  the  small  ridge  in  the 
vagina  joined  or  disappeared  in  the  wall  of  the  urethra.  I  at  once 
concluded  that  this  ridge  contained  a  patent  Gartner's  duct  that  was 
the  source  of  the  discharge.  Several  other  careful  and  prolonged 
efforts  were  made  to  probe  the  duct  in  order  to  confirm  the  diagno- 
sis, but  without  success. 

Though  much  gratified  with  having  discovered  with  reasonable 
certainty  the  nature  of  the  trouble,  1  was  perplexed  about  the  treat- 
ment, but  finally  determined  to  close  the  entrance  of  tlie  duct  into 
the  urethra.  This  was  accomplished  by  passing  a  ligature  round 
that  portion  of  the  vaginal  wall  (close  to  the  urethra)  which  was 
presumed  to  contain  the  duct.  The  ligature  was  tied  quite  tight, 
and,  to  my  great  satisfaction,  the  discharge  w^as  promptly  and  com- 


PATENCY  OP  GARTNER'S  DUCT.  875 

pletelj  stopped.  The  following  day  the  ridge  in  the  vagina  was 
enlarged  considerably,  most  at  the  upper  portion.  This  coniirmed 
the  diagnosis  of  a  patent  Gartner's  duct.  I  then  divided  the  ridge 
or  fold  of  the  vagina  just  above  the  ligature,  and  about  c  drachm  or 
two  of  clear  fluid  escaped.  I  then  cut  away  the  whole  of  the  ridge 
of  the  vagina.  In  the  portion  thus  removed  I  found  the  duct,  which 
was  very  small  at  the  lower  part,  but  large  enough  at  the  upper  part 
to  admit  a  pocket-case  probe. 

There  was  some  bleeding,  which  was  arrested  with  a  tampon. 
The  vaginal  wound  healed  readily,  leaving  the  end  of  the  duct  open 
through  which  the  probe  could  be  passed  up  to  the  parovarium.  A 
clear  discharge,  in  diminished  quantity,  continued.  Tincture  of 
iodine  with  five  per  cent  of  carbolic  acid  was  injected  into  the  duct. 
After  this  there  was  pain  and  some  rise  of  temperature,  which  sub- 
sided in  about  thirty-six  hours.  Several  days  after  this  there  was  a 
slightly  colored  discharge,  very  small  in  quantity,  which  subsided 
completely,  and  there  was  an  end  to  the  trouble.  Apparently  the 
portion  of  the  duct  left  became  obliterated.  All  examinations  were 
made  and  the  treatment  employed  without  ansesthesia,  which  shows 
that  my  patient  possessed  remarkable  self-control  and  was  quite 
heroic. 

This  is  the  first  case  of  patency  of  Gartner's  duct  opening  into 
the  urethra  that  I  have  ever  seen  ;  neither  have  I  found  any  such 
case  recorded  in  the  literature  on  the  subject.  It  must  be  of  special 
interest  to  the  profession  on  account  of  its  being  unique,  the  difficul- 
ties of  diagnosis,  and  the  special  treatment  required,  which  proved 
successful.  The  subject  is  of  personal  interest  because  it  confirms 
the  opinion  that  I  have  always  held,  that  Gartner's  ducts  are  quite 
distinct  from  the  ducts  of  the  urethral  glands,  which  I  described 
years  ago. 

This  whole  subject  has  been  treated  in  an  original  and  masterly 
way  by  Amand  Eouth,  M.  D.,  B.  S.,  M.  E.  C.  P.,  in  vol.  xxxvi  of 
the  "  Transactions  of  the  Obstetrical  Society  of  London."  In  this 
valuable  contribution,  entitled  "  On  Cases  of  Associated  Parovarian 
and  Vaginal  Cysts  formed  from  a  Distended  Gartner's  Duct,"  he 
gives  the  history  of  cases  occurring  in  his  own  practice  and  that  of 
others.  He  also  relates  two  cases  in  which  the  persistent  Gartner's 
duct  opened  into  the  vagina.  One  is  by  Mr.  Milton,  of  Cairo, 
Egypt,  and  the  other  by  Lawson  Tait.  The  following  gives  Dr. 
Routh's  views  on  this  question  : 

"  Details  of  three  cases  of  the  above  are  given,  and  also  of  two 
analogous  cases  of  patency  of  the  whole  length  of  the  duct,  with  an 


876  DISEASES  OF   WOMEN. 

anterior  opening  allowing  free  discharge,  and  thus  preventing  dis- 
tention of  the  duct  along  its  course. 

"  Comparison  is  drawn  between  such  cases  and  those  of  distended 
but  imperforate  Miiller's  ducts. 

"  Evidence  adduced  from  these  cases  is  thought  to  establish,  or 
at  least  to  render  plausible,  the  following  propositions : 

"  1.  That  Giirtner's  duct  can  be  traced  in  some  cases  in  the  adult 
female  from  the  parovarium  to  the  vestibulum  vulvae,  ending  just 
beneath  and  slightly  to  one  side  of  the  urethral  orifice. 

"  2.  Homology  tends  to  show  that  Max  Schiiller's  glands  are 
diverticula  of  Gartner's  ducts,  just  as  the  vesiculee  seminales  are 
diverticula  of  the  vasa  deferentia.  Some  evidence  is  given  that 
Skene's  ducts  are  not  necessarily  identical  with  the  anterior  termi- 
nation of  Gartner's  ducts  (as  most  of  those  who  have  traced  Gart- 
ner's duct  to  the  vestibule  have  thought),  but  that  Skene's  ducts  lead 
directly  and  solely  from  Max  Schiiller's  urethral  glands,  Gartner's 
ducts  being  continued  to  the  vestibule,  behind  but  parallel  to  Skene's 
ducts. 

"  3.  That  Gartner's  duct,  if  patent,  may  become  distended 
at  any  part  of  its  course,  constituting  a  variety  of  parovarian 
cyst  if  the  distention  be  in  the  broad-ligament  portion,  and  a  vagi- 
nal cyst  if  the  distention  be  in  the  vaginal  portion.  The  cases 
described  are  instances  of  the  association  of  both  of  these  cysts, 
owing  to  simultaneous  patency  and  distention  of  both  portions  of 
the  duct. 

"  4.  Attention  is  drawn  to  these  cases  as  affording  explanations 
of  some  obscure  cases  of  profuse  watery  discharge  from  the  vagina, 
not  coming  from  the  uterus  or  bladder. 

"  5.  The  question  of  treatment  is  also  approached,  and  the  opin- 
ion is  expressed  that  where  the  whole  duct  is  distended  the  vaginal 
part  of  the  cyst  may  be  laid  open  as  far  as  the  base  of  the  broad 
ligament,  and  the  broad-ligament  portion  encouraged  to  contract  and 
close  up. 

"  A  very  valuable  work  on  '  The  Duct  of  Giirtner,'  by  Bland  Sut- 
ton, was  published  in  1886,  giving  his  results  of  examinations  of 
seventy  cows ;  and  Mr.  Alban  Doran,  in  his  review  of  this  work, 
points  out  that  as  Gartner's  ducts  are  generally  admitted  to  be  the 
homologues  of  the  vasa  deferentia,  and  as  the  vesiculge  seminales  are 
diverticula  of  the  vasa,  close  to  their  termination  on  the  floor  of  the 
prostatic  urethra,  it  follows  that  the  ]\Iax  Schiiller's  glands  of  the 
female  urethra  are  the  homologues  of  the  vesiculge  seminales,  and 
he  believes  with  Bland  Sutton  in  thinking  that  in  woman,  as  in  Bos, 


DISEASES  OF  THE  URETHRA  AND  URETHRAL  GLANDS.    877 

Skene's  tubes  represent  the  anterior  termination  of  Gartner's  ducts. 
This  latter  conchision  is  not,  I  think,  correct. 

"When  this  view  was  expressed  in  1886,  no  cases  liad  been  pub- 
Hshed  of  a  persistent  Gartner's  duct  opening  at  tlie  base  of  the  ves- 
tibule ;  but  the  cases  now  given,  and  other  cases  of  cysts  formed  out 
of  the  vaginal  portion  of  Gartner's  ducts,  show  that  the  opening  of 
Skene's  ducts  and  the  opening  of  Gartner's  ducts  are  not  neces- 
sarily identical  in  situation." 

I  am  glad  to  add  this  case  in  further  evidence  of  the  ground 
taken  in  my  first  studies  in  this  department. 


DISEASES    OF    THE    URETHRA    AND    URETHRAL    GLANDS, 

The  diseases  which  affect  the  urethra  and  its  glands  may  be 
divided  into  two  classes : 

I.  Functional  diseases. 

II.  Organic  diseases. 


I.   FUNCTIONAL  DISEASES   OF   THE   URETHRA. 

I  know  of  but  one  form  of  affection  which  properly  comes  under 
this  head,  and  that  is  commonly  denominated  neuralgia.  A  case  will 
be  occasionally  met  in  which  there  are  pain  and  tenderness  of  the 
urethra,  with  frequent  desire  to  urinate,  and  pain  in  doing  so.  In 
short,  there  is  a  history  of  subacute  urethritis ;  but,  upon  the  most 
careful  examination  that  can  be  made,  with  all  the  means  at  one's 
command,  there  will  be  failure  to  find  any  lesions  to  account  for  the 
symptoms  present.  To  this  condition  the  name  neuralgia  has  been 
applied,  rather  improperly,  no  doubt.  From  my  own  observation  of 
this  affection,  in  which  there  are  well-marked  symptoms,  with  no 
apparent  anatomical  lesions,  I  have  been  led  to  the  conclusion  that 
it  is  a  disease  of  the  nerves  of  the  part — one  of  the  neuroses,  as  they 
are  called.  It  is  quite  possible,  however,  that  progress  in  the  diag- 
nosis of  urethral  diseases  may  yet  enable  diagnosticians  to  find  lesions 
other  than  of  the  nerves  to  account  for  the  sym]5toms  presented  by 
the  disease  in  question.  But  for  the  present  it  must  be  classed 
among  the  neuroses. 

So  far  as  I  know,  it  is  an  affection  peculiar  to  young  women.  I 
have  only  seen  it  among  young  married  women  of  marked  nervous 
temperament,  and  who  have  not  borne  children.  In  some  of  the 
cases  observed,  it  was  associated  with  an  irritable  condition  of  the 
introitus  vulvse. 


878  DISEASES  OF  WOMEN. 

The  symptoms  are  such  as  occur  in  a  great  variety  of  pathologi- 
cal conditions,  and  are,  therefore,  of  little  value  in  guiding  to  a  cor- 
rect idea  of  the  real  trouble  ;  and,  as  there  are  no  diagnostic  physical 
signs  present,  the  diagnosis  must  be  made  by  exclusion.  The  most 
thorough  examination  of  the  urine  should  be  made,  and  the  urethra 
and  neighboring  organs  should  be  carefully  investigated.  Perhaps 
the  greatest  liability  to  error  lies  in  mistaking  this  condition  for 
reflex  irritation  of  the  urethra  and  bladder,  arising  from  ovarian, 
uterine,  or  rectal  disease.  Careful  inquiry  into  the  condition  of 
those  organs  should  therefore  be  made  before  concluding  that  the 
disease  is  of  the  urethra  itself. 

The  affection  is  fortunately  rare  as  well  as  obscure.  I  will,  there- 
fore, relate  the  history  of  some  cases,  which  will  give  the  facts  as 
they  were  obseiwed  chnically. 

ILLUSTRATIVE   CASES. 

One  case  was  that  of  a  lady  of  a  highly  nervous  temperament, 
whose  parents  died  of  tuberculosis.  She  was  twenty-six  years  of  age, 
and  had  been  married  three  years.  From  the  time  of  her  marriage 
she  began  to  suffer  from  painful  menstruation  and  uterine  Jeucor- 
rhoea.  She  attributed  her  trouble  to  getting  cold  while  driving  in 
an  open  carriage  behind  a  fast  horse.  She  had  an  anteflexion  of  the 
uterus  and  cervical  endometritis.  The  right  ovary  was  large,  tender, 
and  prolapsed.  Before,  during,  and  after  her  menses  she  had  smart- 
ing and  burning  pain  in  the  urethra,  with  a  feeling  of  spasmodic 
contraction,  which  sometimes  rendered  urination  difficult  and  pain- 
ful. In  the  interval  between  the  menstrual  periods  she  had  tender- 
ness of  the  urethra  and  discomfort  in  passing  urine. 

The  urethra  was  repeatedly  examined  throughout  its  whole  extent 
with  the  endoscope,  but  no  disease  could  be  found,  only  tenderness 
and  spasmodic  action. 

She  derived  relief  from  suppositories  of  morphine  and  bella- 
donna, but,  when  last  seen,  she  still  had  attacks  of  the  same  trouble. 
It  was  supposed,  at  first,  that  the  urethral  trouble  was  due  to  the 
disease  of  the  uterus,  but  the  former  persisted  after  the  latter  was 
relieved. 

Another  case  was  that  of  a  lady,  aged  twenty-nine,  who  had  been 
married  for  seven  years,  but  had  never  been  pregnant.  She  was  of  a 
highly  nervous  temperament,  but  her  general  health  had  always  been 
good.  She  began  to  menstruate  at  fourteen  years  of  age,  and  con- 
tinued to  do  so  regularly,  but  scantily.  For  several  years  she  had 
suffered  from  backache  and  slight  uterine  leucorrhoea,  and  coitus  had 


ORGANIC  DISEASES  OF   THE   URETHRA.  8Y9 

always  been  painful.  Slie  had  frequent  and  painful  urination.  The 
ntenis  was  small — in  fact,  all  the  reproductive  organs  were  under- 
sized. There  was  marked  tenderness  of  the  introitus  vulvae.  The 
remains  of  the  hymen  were  very  tender,  and  at  the  meatus  urinarius 
and  on  the  vestibule  there  were  a  number  of  quite  small  papillomata 
(of  the  same  color  as  the  mucous  membrane)  that  were  also  exceed- 
ingly tender.  These  were  destroyed  by  an  application  of  equal  parts 
of  carbolic  acid  and  tincture  of  iodine,  and  the  leucorrhcea  was  ar- 
rested by  the  usual  treatment.  This  relieved  her  of  aii  the  symptoms 
except  those  of  the  urinary  organs.  Her  urine  was  examined  repeat- 
edly, and  was  found  to  be  normal.  The  urethra  was  also  investi- 
gated, but  nothing  wrong  was  found  there  except  that  the  papillae 
appeared  to  be  unusually  prominent.  I  learned  that  if  she  retained 
the  urine  for  an  hour  or  two  the  desire  to  urinate  passed  off,  and 
did  not  return  until  the  bladder  was  fully  distended.  When  she  did 
urinate,  the  desire  to  empty  the  bladder  continued — i.  e.,  she  had 
vesical  tenesmus — but,  if  she  indulged  this  feeling  by  passing  the 
urine  repeatedly,  this  tenesmus  continued ;  while,  if  she  resisted  the 
desire,  it  gradually  subsided.  This  proved  conclusively  that  the 
cause  of  the  frequent  urination  was  the  condition  of  the  urethra. 

Quite  a  variety  of  agents,  which  I  need  not  give  in  detail  here, 
were  tried  in  this  case.  Suffice  it  to  say  that  she  only  derived  bene- 
fit from  coating  the  entire  mucous  membrane  of  the  urethra  with 
dry  subnitrate  of  bismuth  once  a  day  for  a  week,  and  then  applving 
equal  parts  of  tincture  of  aconite  and  aqueous  extract  of  opium 
twice  a  week  for  a  time.  The  bismuth  was  made  into  an  emulsion 
with  water  and  a  little  acacia,  and  applied  with  the  pipette.  A  steel 
sound  was  also  passed  once  a  week,  and  allowed  to  remain  in  place 
for  about  five  minutes.  This  gave  pain  at  the  time,  but  relief  fol- 
lowed. During  the  local  treatment  she  took  nourishing  food,  iron, 
and  arsenic.  She  may  be  said  to  have  recovered  ;  but  overtaxation, 
mental  or  physical,  would  bring  back  the  trouble  in  a  slight  degree 
for  a  short  time. 


II.  ORGANIC  DISEASES  OF  THE  URETHRA. 

This  class  may  be  subdivided  into  ten  groups. 

1.  Inflammation  or  urethritis. 

2.  Granular  erosion. 

3.  Vesico-urethral  fissure. 

4.  Neoplasms. 

5.  Dilatation. 


880  DISEASES   OF  WOMEN. 

6.  Dislocation. 

T.  Prolapsus. 

8.  Stricture. 

9.  Foreign  bodies. 
10.  Fistula. 

1.  Inflammation  of  the  Urethra,  or  Urethritis. — This  is  of  three 
varieties  [a)  acute,  (J)  chronic,  and  {c)  gonorrhoeal. 

Acute  urethritis,  though  not  a  very  frequent  disease  among 
women,  is  a  very  distressing  one,  and  often  difficult  to  relieve.  In 
many  cases  it  will  be  found  to  depend  upon  a  speciiic  cause,  that  is, 
gonorrhoea  ;  and  I  would  treat  this  subject  as  gonorrhoea  in  women, 
were  it  not  that  it  is  often  difficult  to  tell  a  specific  or  venereal  ure- 
thritis from  simple  inflammation  of  that  portion  of  mucous  mem- 
brane. There  is  a  difference  in  tlie  history  when  correct  testimony 
is  obtained  from  the  patient.  Simple  urethritis  usually  comes  on 
gradually,  and  is  often  preceded  by  symptoms  of  uterine  or  vesical 
disease ;  while  the  gonorrhceal  variety  comes  on  rather  abruptly,  and 
is  preceded  or  attended  by  acute  vaginitis  and  vulvitis.  The  chief 
symptom  in  both  varieties  is  painful  urination.  Sharp  scalding  is 
l^roduced  by  the  urine  passing  over  the  tender  surface.  There  is 
often  a  frequent  desire  to  urinate,  but  not  so  urgent  as  in  cystitis.  In 
some  cases  the  urine  is  retained  for  a  long  time,  evidently  from  a 
dread  of  the  pain  caused  in  passing  it. 

In  quite  a  number  of  cases  I  have  noticed  haemorrhage.  That 
the  blood  comes  from  the  urethra  is  known  by  the  fact  that  it  is  not 
intimately  mixed  with  the  urine ;  and  after  micturition  it  will  ooze 
from  the  meatus  uri  nanus. 

An  examination  of  the  parts  will  show  signs  of  inflammation 
about  the  meatus,  with  or  without  the  same  condition  of  the  vulva. 
Occasionally,  there  is  a  discharge  seen  coming  from  the  urethra,  but 
if  the  ])arts  have  been  recently  bathed  this  may  not  be  apjiarent. 
Introducing  the  finger  into  the  vagina,  and  pressing  upon  the  urethra 
from  above  downward,  the  discharge  can  be  started,  unless  the  pa- 
tient has  passed  water  immediately  before.  The  appearance  of  the 
discharge  corresponds  to  that  of  gonorrhoea  in  its  various  stages. 
An  examination  of  the  discharge  with  the  microscope  may  reveal 
the  presence  of  the  gonococcus,  and,  if  so,  that  will  determine  the 
nature  of  the  urethritis.  The  absence  of  that  germ  is  not  positive 
proof  that  the  inflammation  is  not  gonorrhoeal,  unless  frequent  and 
skilled  examinations  fail  to  find  it. 

Cystitis,  wliich  is  liable  to  be  confounded  with  urethritis,  may  be 
excluded  by  using  the  catheter,  and  after  letting  urine  flow  for  a 


ORGANIC  DISEASES  OF   THE  URETHRA.  881 

time,  collecting  the  remainder  for  examination.  The  raucous  mem- 
brane, as  seen  through  the  endoscope,  is  of  a  deep  red,  with  pus  or 
mucus  lodged  in  its  folds.  The  instrument  can  not  be  used  in  all 
cases,  owing  to  the  acute  tenderness  of  the  parts.  Bleeding  is  very 
likely  to  occur  at  the  examination,  simply  from  the  contact  of  the 
endoscope. 

The  treatment  of  acute  urethritis,  whether  specific  or  not,  may  be 
conducted  on  the  same  principles  as  that  of  gonorrhoea  in  the  male, 
using  the  same  constitutional  remedies,  local  baths,  etc.  This  will 
suffice  in  most  cases  of  acute  disease ;  but  when  it  assumes  the  sub- 
acute form  from  the  beginning,  then  the  use  of  injections  becomes 
necessary. 

Dr.  Avery  Segur,  of  Brooklyn,  finds  that  the  discharge  of  gonor- 
rhoea is  markedly  lessened,  and  sometimes  cured,  by  ten-grain  doses 
of  salicylic  acid,  given  in  solution  several  times  a  day. 

I  have  seen  much  benefit  derived  from  douching  the  urethra 
with  water  as  hot  as  the  patient  could  bear  it.  For  this  purpose  I 
use  a  catheter  made  like  the  fluted  roller  of  a  crimping-machine,  the 
appearance  of  which  is  doubtless  familiar,  Fig.  271.    Inside  the  cath- 


Fig.  271. — Skene's  reflux  catheter. 

eter  there  is  a  small  supply-tube,  which  conveys  the  water  to  the 
rounded  point  of  the  instrument.  Behind  the  point  of  the  catheter, 
where  the  grooves  terminate,  there  is  a  perforation  in  each  groove 
through  which  the  water  returns.  By  this  arrangement  the  water  as 
it  flows  back  through  the  grooves  is  brought  in  contact  with  every 
portion  of  the  mucous  membrane.  The  instrument  is  passed  up  to 
the  neck  of  the  bladder,  and  a  fountain -syringe  attached  to  it,  and 
the  water  as  it  flows  away  is  caught  in  a  cup. 

The  injection  of  solutions  of  nitrate  of  silver,  sulphate  of  zinc, 
and  the  like,  will  often  prove  useful.  It  must  be  home  in  mind  that 
the  female  urethra  will  not  hold  more  than  ten  or  fifteen  drops,  and 
if  more  is  used  it  will  enter  the  bladder,  even  where  but  very  slight 
force  is  employed  while  injecting.  I  use  a  large  pipette,  placing 
the  nozzle  over  (not  in)  the  meatus,  and  inject  slowly  and  without 
force  a  small  quantity.  When  the  case  is  of  long  standing,  and  the 
neck  of  the  bladder  appears  to  be  involved  also,  I  use  a  mild  injec- 
tion of  one  or  two  grains  of  nitrate  of  silver  to  the  ounce,  and  inject 
57 


882  DISEASES  OF  WOMEN. 

it  through  the  uretlira  with  force  enough  to  enter  the  bladder,  and 
let  it  remain  there,  to  be  passed  off  when  the  patient  urinates.  In 
acute  urethritis  the  most  efficient  treatment  that  I  have  found  is  to 
wash  out  the  uretlira  with  the  reflux  catheter  two  or  three  times  a 
day,  and  then  introduce  a  suppository  of  iodoform  in  cocoa-butter,  or 
bismuth  and  cocoa-butter.  In  old  cases,  which  began  by  a  severe 
acute  attack,  and  where  the  walls  of  the  urethra  are  very  much 
thickened  and  the  canal  contracted,  dilatation  with  bougies  does 
much  good.  While  the  bougie  is  passed  once  or  twice  a  week,  I 
apply  to  the  vaginal  portion  of  the  uretlira  oleate  of  mercury  or  the 
unguentum  hydrargyri.  This  will  often  suffice  to  stop  the  gleety  dis- 
charge, as  well  as  remove  the  thickening  of  the  urethral  walls.  The 
case  reported  by  Dr.  Howard,  which  will  be  found  at  the  close  of 
the  consideration  of  the  diseases  affecting  the  urethral  glands,  would 
seem  to  indicate  that  a  gonorrhoeal  urethritis  in  which  these  glands 
are  involved  may  continue  indefinitely  unless  appropriate  treatment 
is  directed  to  them. 

Treatment  of  Chronic  Urethritis  and  Spasm  of  the  Bladder. — Dur- 
ing the  past  ten  years  Weiser  has  adopted  a  new  method  of  treat- 
ment in  chronic  gonorrhoea,  and  out  of  twenty-five  cases  he  has  suc- 
ceeded in  curing  all  but  one.  The  latter  was  afterward  advised  to 
consult  Dr.  Greenfeld,  who,  by  means  of  the  endoscope,  discovered 
granulations  in  the  uretbra,  which  being  cauterized,  the  man  got 
well  after  several  weeks'  treatment.  Weiser  first  passes  an  elastic  or 
metallic  catheter  into  the  bladder,  and,  after  thoroughly  evacuating 
the  viscus,  injects  into  it  by  means  of  a  clysopompe,  or,  preferably, 
an  irrigator,  a  solution  of  sulphate  of  zinc,  2  to  3,  and  tannin,  0*5 
in  500  of  water,  at  a  temperature  of  26°  E.  The  catheter  is  then 
withdrawn,  and  the  patient  directed  to  empty  his  bladder,  thus  bring- 
ing the  medicated  solution  in  thorough  contact  with  the  whole  of  the 
urethra.  This  method  is  effectual  in  all  cases  when  no  granulations 
exist.     The  latter  require  the  application  of  caustics. 

The  author  has,  however,  omitted  to  state  how  long  the  treat- 
ment must  be  continued.  In  cases  with  associated  cystitis  three  to 
f(jur  drops  of  nitrite  of  amyl  should  be  added  to  the  above  solution, 
the  former  being  a  very  active  disinfectant — one  or  two  drops  added 
to  a  bottle  of  urine  serving  to  prevent  the  development  of  anmionia 
in  the  latter  for  a  couple  of  years.  When  strictures  are  present  they 
should  be  treated  with  metallic  sounds.  For  the  relief  of  cysto- 
spasms,  the  above-mentioned  solution  may  also  be  employed  ;  one  or 
two  injections  a  day,  continued  for  an  average  period  of  three 
months,  usually  suffice  to  entirely  cure  this  condition.     Frictions 


ORGANIC  DISEASES  OF   THE  URETHRA.  883 

with  cold  water  and  lukewarm  (2C°  R.)  sitz-baths  may  be  employed 
as  adjuvants. — "  Mittheilungen  des  Wiener  Med.,  Doatoren-CoUeyi- 
ums,  June  23,  1881 ;  New  York  Medical  Reoord,  October  1,  1881, 
p.  375. 

A  Case  of  Chronic  Urethritis  treated  by  Emmet's  Button-Hole 
Operation.  (By  Yirgil  O.  Hardon,  M.  D.,  Atlanta,  Ga.) — E.  J.,  white, 
widow,  aged  sixty-one,  was  married  at  thirteen,  and  has  borne  nine- 
teen children.  All  her  labors  were  normal,  as  far  as  she  knows,  and 
her  health  had  always  been  good  until  twelve  years  ago.  .  She  then 
began  to  suffer  from  frequent  desire  for  micturition,  and  the  act  was 
always  accompanied  by  burning  pains.  These  symptoms  gradually 
increased  in  severity,  until  at  the  present  time  she  is  obliged  to  uri- 
nate at  intervals  of  from  iifteen  to  thirty  minutes  throughout  the  day 
and  night.  The  passage  of  urine  produces  an  intense  pain  in  the 
urethra,  especially  at  the  meatus,  radiating  upward  into  the  abdomen 
and  downward  into  the  thighs.  This  pain  persists  for  some  time 
after  micturition,  so  that  she  is  hardly  ever  free  from  it.  In  other 
respects  her  health  is  good,  but  her  naturally  robust  constitution  is 
breaking  down  under  the  constant  pain  and  annoyance  to  which  she 
is  subjected.  She  is  entirely  unfitted  for  social  or  domestic  duties, 
and  nearly  her  whole  time  and  attention  are  given  to  keeping  her 
bladder  empty. 

Examination  shows  the  meatus  contracted  so  as  to  scarcely  admit 
a  No.  6  sound,  and  surrounded  by  cicatricial  tissue,  forming  bands 
by  which  it  is  much  distorted.  Extreme  tenderness  exists  along  the 
urethra  and  in  the  neck  of  the  bladder.  The  passage  of  a  sound 
gives  exquisite  pain.  The  urethro-vaginal  septum  is  of  abnormal 
thickness  and  density.  Otherwise  the  pelvic  organs  are  found  to  be 
normal. 

The  urine,  of  which  about  an  ounce  is  passed  at  a  time,  is  straw- 
colored  and  slightly  turbid.  Upon  standing  there  is  formed  a  de- 
posit of  about  one  fourth  its  bulk  ;  specific  gravity,  1028.  Chem- 
ical and  microscopical  examination  shows  it  to  be  free  from  albu- 
men, sugar,  pus,  and  mucus.  The  deposit  is  made  up  of  amorphous 
urates. 

The  patient  has  been  treated  by  internal  medication  by  compe- 
tent practitioners,  but  without  receiving  any  apparent  benefit. 

January  23,  1886,  with  the  assistance  of  Drs.  Bizzell  and  Wile, 
she  was  etherized,  and  Emmet's  button-hole  opei-ation  was  per- 
formed. An  incision  was  made  through  the  urethro-vaginal  sep- 
tum, commencing  a  quarter  of  an  inch  behind  the  meatus  and  ex- 
tending so  a  quarter  of  an  inch  from  the  neck  of  the  bladder. 


884  DISEASES  OF  WOMEN. 

Through  this  opening  the  cut  edge  of  the  urethral  mucous  mem- 
brane was  drawn,  and  stitched  on  all  sides  to  the  cut  edge  of  the 
vaginal  mucous  membrane  with  carbolized  silk  sutures.  Thus  no 
surface  was  left  uncovered  to  heal  by  granulation.  The  urethral 
mucous  membrane  was  found  to  be  so  intensely  congested  as  to  pre- 
sent a  deep  purple  color,  and  capillary  oozing  of  blood  from  it  was 
very  free.  The  parts  were  smeared  with  vaseline,  and  the  patient 
was  afterward  instructed  to  make  the  same  application  before  each 
micturition.  The  wound  healed  satisfactorily,  and  the  sutures  were 
removed  on  the  eighth  day,  leaving  a  permanent  urethro-vaginal 
fistula. 

In  the  twenty-four  hours  following  the  operation  the  patient 
urinated  five  times,  with  only  slight  pain.  After  the  second  day 
she  was  entirely  free  from  pain,  and  has  continued  so  ever  since. 
She  urinates  sometimes  twice,  usually  only  once,  and  occasionally 
not  at  all  during  the  night,  and  from  four  to  six  times  during  the 
day.  She  frequently  holds  her  urine  for  six  hours  without  any  dis- 
comfort. The  urine  passes  entirely  through  the  artificial  opening. 
The  pain  at  the  meatus  and  the  tenderness  along  the  uretlu-a  have 
ceased,  and  the  congestion  of  the  urethral  mucous  membrane  is  now 
very  slight. — Atlanta  Medical  and  Surgical  Journal. 

2.  Granular  Erosion. — This  very  troublesome  affection  of  the 
urethra  may  result  from  urethritis,  or  may  appear  without  any  pre- 
vious disease.  The  mucous  membrane  is  covered  with  young,  im- 
perfectly developed  epithelium  ;  the  papillae  are  hypertrophied  and 
extremely  sensitive.  This  gives  rise  to  the  most  excruciating  pain 
during  micturition,  and  generally  keeps  up  a  distressing  tenesmus. 
This  disease  is,  fortunately,  not  very  common.  Old  people  are  most 
liable  to  suffer  from  it.  The  diagnosis  is  made  from  the  history  and 
appearance  of  the  urethra.  The  treatment  which  is  most  reliable  is 
cauterization  of  the  whole  surface.  The  milder  washes  and  injec- 
tions do  not  accomplish  much.  Pure  carbolic  acid  may  be  tried 
first,  brushing  it  over  the  surface,  and  repeating  it  in  eight  or  ten 
days.  This  is  the  least  painful  application,  and  answers  in  some 
cases.  "When  it  fails,  a  solution  of  nitrate  of  silver  (one  drachm  to 
the  ounce)  should  be  used.  In  some  cases  it  is  desirable  before 
using  strong  caustics  to  dilate  the  urethra,  and  then  touch  it  with 
carbolic  acid  in  a  mild  solution,  say  two  per  cent. 

Among  the  inflammatory  affections  of  the  female  urethra  are 
mild  forms  of  congestion  and  irritation,  that  fall  short  of  well- 
marked  urethritis.  Indeed,  some  of  these  attacks  amount  to  little 
more  than  congestion  or  slight  catarrh.     In  others,  I  h  ve  found 


ORGANIC   DISEASES   OF  THE  URETHRA.  885 

circumscribed  patches  of  the  urethra  inflamed,  and  tlie  rest  of  the 
canal  normal. 

There  is  little,  if  anything,  in  medical  works  on  the  subject  of 
these  mild  yet  troublesome  affections,  and  I  hope  that  a  clear  idea  of 
the  subject  will  be  gained  from  the  narration  of  some  cases  which 
have  come  under  my  observation. 

ILLUSTEATIVE   CASES. 

A  young,  married  lady  had  been  under  my  care  for  dysmenor- 
rhoea  caused  by  anteflexion.  She  had  recovered  sufiiciently  to  be- 
lieve that  she  was  well  enough  to  go  to  a  party  and  dance  to  excess, 
which  she  did,  and  caught  cold  on  the  way  home.  On  the  second 
day  after  I  was  called  to  see  her,  and  found  her  with  the  usual 
symptoms  of  an  ordinary  cold,  that  caused  her  little  anxiety.  But 
she  was  suffering  severely  from  frequent  and  painful  micturition. 
I  found  slight  general  congestion  of  the  uterus  and  vagina,  and  sus- 
pected cystitis,  but  the  urine  was  normal.  I  then  examined  the 
urethra,  and  found  it  congested  throughout,  and  with  streaks  of 
mucus  lodged  in  the  folds  of  the  membrane.  There  was  neither 
erosion  nor  ulceration. 

I  directed  her  to  rest  quietly  in  bed,  and  drink  freely  of  flaxseed- 
tea  and  spiritus  setheris  nitrosi.  A  suppository  containing  one 
quarter  of  a  grain  of  extract  of  belladonna  and  a  sixth  of  a  grain  of 
sulphate  of  morphia  was  directed  to  be  introduced  into  the  vagina 
at  bed-time.  Under  this  simple  treatment  she  rapidly  improved. 
Twelve  days  after  the  date  of  my  visit  she  called  to  see  me,  and  I 
then  found  that  she  could  retain  her  urine  for  hours,  but  still  had 
slight  pain  and  burning  during  micturition.  The  urethra  was  again 
examined  with  the  endoscope,  and  a  few  red  patches  found  scat- 
tered here  and  there  along  the  canal.  This  was  all  that  remained  of 
the  trouble.  Liquor  bismuthi,  sufficient  in  amount  to  fill  the 
urethra,  was  injected  every  second  day  for  a  week,  when  she  de- 
clared herself  quite  well. 

A  second  case  was  that  of  a  young  lady,  healthy  and  active,  who 
was  head  saleswoman  in  a  department  of  a  large  dry -goods  estab- 
lishment. During  the  holidays,  from  Christmas  to  New  Year's,  she 
was  on  her  feet  from  eight  in  the  morning  until  ten  or  eleven  at 
night.  On  the  last  day  of  the  year  she  was  seized  with  pain  and 
burning  in  the  urethra,  and  soon  after  she  began  to  suffer  from  fre- 
quent and  painful  micturition. 

Three  or  four  days  after  the  attack  I  examined  the  urethra,  and 
found  several  small  ecchymoses  at  various  parts  of  the  mucous  mem- 


886  DISEASES  OF   WOMEN. 

brane,  the  highest  one  being  near  the  neck  of  the  bladder.  These 
spots  were  due  to  haemorrhages  that  bad  taken  place  into  the  mucous 
membrane,  beneath  the  epithelial  layer.  The  spots  were  dark,  al- 
most black  in  the  center,  and  surrounded  by  an  inflamed  border, 
which  was  bright  red  at  the  inner  margin,  but  gradually  shaded  ofl: 
into  the  natural  color  of  the  surrounding  mueous  membrane. 

My  idea  of  the  pathology  of  this  case  is  that  the  congestion  aris- 
ing from  the  maintenance  of  the  erect  position  for  so  long  a  time 
caused  some  of  the  small  vessels  to  rupture,  and  the  haemorrhage 
into  the  membrane  produced  little  circumscribed  spots  of  inflam- 
mation. 

She  was  directed  to  rest  in  the  recumbent  position,  and  drink 
freely  of  Yichy  water.  This  she  did,  and  made  a  good  recovery ; 
but  it  was  six  or  eight  days  before  the  pain  in  urinating  left  her 
entirely. 

It  will  be  observed  that  these  cases  were  both  acute,  and  recov- 
ered very  promptly ;  and  I  could  give  several  more  histories  which 
might  lead  to  the  supposition  that  such  trivial  ailments  of  the  ure- 
thra are  not  of  much  importance  after  all.  It  might  also  be  pre- 
sumed that  this  form  of  urethral  disease  would  disappear  in  most 
cases  without  being  treated.  This  is  no  doubt  true,  but  they  do 
not  all  recover  spontaneously.  Some  of  these  mild  cases  tend  to 
continue.  They  become  chronic,  and  if  neglected  will  continue  for 
years,  to  the  great  annoyance  of  the  subject.  Of  the  chronic  or 
continuous  fonn  of  urethritis  the  following  are  good  examples :  A 
single  woman,  thirty  years  of  age,  had  for  ten  years  been  occupied 
as  dressmaker,  and  was  in  the  habit  of  operating  a  sewing-machine 
occasionally.  Her  general  health  had  always  been  excellent,  but  she 
consulted  me  for  what  she  supposed  to  be  an  affection  of  the  kid- 
neys. She  said  that  for  five  years  she  had  been  annoyed  with  pain- 
ful and  frequent  micturition.  She  was  obliged  to  urinate  every  two 
or  three  hours  during  the  day,  and  several  times  in  the  night. 
Standing,  walking,  or  exposure  to  cold  invariably  made  her  worse. 

An  examination  of  her  pelvic  organs  revealed  slight  catarrh  of 
the  cervix  uteri,  and  a  mild  vaginitis,  limited  to  the  upper  and  pos- 
terior portion  of  the  vagina,  most  marked  behind  the  cervix.  Her 
urine  was  examined  carefully  and  found  to  be  normal.  The  urethra 
was  then  examined  by  the  endoscope,  which  brought  to  view  a 
highly  inflamed  spot  on  the  anterior  wall  of  the  urethra,  and  an  in- 
flamed ulcer  on  the  posterior  wall.  Tlie  disease  was  limited  to  the 
middle  third  of  the  urethra,  and,  while  extending  all  around,  was 
most  marked  anteriorly  and  posteriorly.     The  ulcer,  which  lay  in 


ORGANIC   DISEASES  OF   THE  URETHRA.  887 

the  posterior  wall  or  floor  of  the  urethra,  was  superficial  and  appeared 
through  the  endoscope  as  a  gray  spot  surrounded  by  a  bright  red 
areola.  It  bled  on  contact  with  or  stretching  by  the  instrument. 
The  color  of  the  nj^por  and  lower  third  of  the  urethra  was  somewhat 
darker  than  usual,  but  otherwise  normal. 

The  recovery  in  this  case  was  somewhat  tedious,  because  it  was 
one  of  my  first  cases,  and  my  treatment  was  experimental  and  not 
always  beneficial.  First,  I  touched  the  inflamed  parts  with  a  solu- 
tion of  nitrate  of  silver  (one  drachm  to  the  ounce),  using  just  enough 
to  whiren  the  surface.  This  gave  her  rather  sharp  pain,  which 
passed  off,  however,  in  a  few  hours.  After  this  she  had  much  pain 
in  passing  water,  but  the  frequency  was  about  the  same  as  before 
the  application.  About  ten  days  after  using  the  solution  the  parts, 
though  still  inflamed,  were  much  improved. 

This  advantage  gained  suggested  a  repetition  of  the  application, 
which  I  made.  It  was  followed  by  very  severe  pain,  that  lasted  two 
days  and  nights  before  it  subsided.  There  was  no  improvement. 
After  this  I  injected  into  the  urethra,  twice  a  week,  a  solution  con- 
sisting of 

^  Zinci  sulphatis gr.  iv. 

Fl.  ext.  hydrastis  Canadensis §  j. 

AquEe §  iij.     M. 

About  half  a  drachm  of  this  was  used  at  a  time.  This  was  con- 
tinued for  about  a  month  with  marked  benefit.  At  the  end  of  that 
time  she  could  rest  all  night  without  urinating,  and  had  to  micturate 
only  about  every  four  hours  during  the  day,  and  had  very  little  pain. 
Injection  of  liquor  bismuthi  (half  a  drachm)  was  then  begun,  and 
continued  twice  a  week  for  three  weeks,  when  she  was  free  from  all 
trouble,  but  was  obliged  to  urinate  every  four  or  six  hours,  from 
habit,  I  suppose. 

One  other  case  may  be  given  to  show  the  disposition  of  this  form 
of  urethral  trouble  to  continue.  This  patient  was  thirty-nine  years 
of  age,  and  had  been  a  widow  for  sixteen  years.  Her  only  child  was 
a  growu-up  woman.  Four  years  before  I  saw  her  she  had  a  catarrh 
of  the  bladder,  for  which  she  was  treated  by  a  skilled  physician. 
She  recovered  from  that  after  a  time,  the  urine  becoming  normal, 
and  the  abiUty  to  retain  it  excellent.  She  continued,  however,  to 
have  pain  in  passing  urine,  but  as  there  was  no  discomfort  at  any 
other  time  she  was  satisfied  to  tolerate  that. 

Being  troubled  ^vith  constipation  while  traveling,  she  was  taken 
with  agonizing  pain  after  defecation,  continuing  to  suffer  ^^'ith  it  for 
several  months.     She  then  applied  to  me  for  relief.     She  stated  that 


888  DISEASES  OF  WOMEN. 

the  pain  during  micturition  had  been  much  worse  since  the  develop- 
ment of  the  rectal  pain.  The  rectum  was  examined  with  the  endo- 
scope (the  same  instrument  used  in  exploring  the  bladder  and 
urethra,  but  of  larger  size),  and  a  well-delined  tissure  detected.  This 
explained  the  rectal  symptoms,  and  it  is  fair  to  suppose  that  the 
urethral  trouble  was  aggravated  by  it  sj-mpathetically.  The  lower 
third  of  the  urethra  was  found  to  be  inflamed,  and  in  places  eroded. 
The  anal  fissure  was  relieved  by  the  usual  operation,  and  the  urethra 
was  treated  with  applications  of  nitrate  of  silver  (one  grain  to  the 
ounce).     Recovery  was  speedy  and  satisfactory. 

3.  Vesico-Urethral  Fissure. — This  affection  holds  an  intermediate 
position  between  cystitis  and  urethritis,  and  in  its  symptomatology 
bears  a  marked  resemblance  to  both,  and  I  have  therefore  deferred 
its  consideration  until  both  these  diseases  have  been  treated,  1  am 
fully  satisfied  that  it  is  often  mistaken  for  infiammation  of  the  blad- 
der or  urethra. 

It  is  only  within  the  last  few  years  that  this  trouble  has  been 
brought  to  the  notice  of  the  profession,  and  hence  there  is  very  little 
in  medical  literature  on  the  subject.  This  affection  has  heretofore 
been  called  fissure  of  the  neck  of  the  bladder.  Were  I  to  name  it 
according  to  its  location,  I  should  say  vesico-urethral  fissure,  for  its 
usual  site  is  at  the  point  of  junction  of  the  two. 

The  lesion,  as  the  name  indicates,  is  a  crack  or  fissure  of  the 
mucous  membrane,  produced  by  ulceration.  It  runs  lengthwise  of 
the  urethra,  and  is  situated  in  one  of  the  sulci  or  folds  of  the  mem- 
brane formed  by  the  corrugations  which  always  exist  when  the 
urethra  is  not  distended.  It  is  usually  spoken  of  as  situated  in  the 
vesical  neck,  but  as  a  rule  two  thirds  of  it  is  situated  in  the  urethra, 
the  upper  end  of  it  only  extending  into  the  bladder. 

It  may  occur  at  any  part  of  the  circumference  of  the  urethra. 
In  the  majority  of  the  cases  that  I  have  examined  it  has  been  situ- 
ated on  the  right  side  anteriorly.  Those  who  are  familiar  with  fis- 
sure of  the  rectum  will  understand  that  fissure  of  the  vesical,  neck 
is  exactly  the  same  in  appearance,  save  that  it  is  much  smaller.  It 
is  from  a  quarter  to  three  eighths  of  an  inch  in  length,  and  from  one 
twelfth  to  one  sixth  of  an  inch  in  width  at  the  center,  but  tapering 
off  at  each  end. 

The  deepest  part  has  a  yellowish  gray  color,  like  that  of  an  in- 
dolent ulcer,  while  the  edges  are  red  and  actually  inflamed,  like 
those  of  an  irritable  ulcer.  When  seen  through  a  large  endoscope 
that  puts  the  parts  upon  the  stretch,  it  may  appear  freshly  torn  and 
bleeding.     The  edges  are  usually  abrupt,  elevated,  and  indurated, 


ORGANIC   DISEASES   OP   THE   URETHRA.  889 

and  of  a  dark  or  bright  red  color.  This  shades  off  gradually  into 
the  normal  membrane  of  the  urethra. 

The  importance  of  this  lesion  depends  upon  its  site.  An  ulcer 
or  fissure  of  the  same  size,  if  situated  in  any  other  portion  of  the 
urethra,  would  cause  little  suffering  beyond  a  smarting  sensation 
during  micturition.  But  occurring  at  the  union  of  the  bladder  and 
urethra  it  is  submitted  to  constant  though  slight  pressure,  which 
causes  severe  and  continuous  pain.  I  believe  tliat  the  very  great 
suffering  caused  by  this  disease  is  due  largely  to  the  fact  that  these 
parts  of  the  bladder  and  urethra  are  by  far  the  most  sensitive,  and 
that  the  upper  portion  of  the  fissure,  which  extends  into  the  bladder, 
is  exposed  to  the  irritation  of  the  urine,  which  excites  the  constant 
desire  to  urinate.  The  pain  which  is  thus  produced  causes  exces- 
sive contraction  of  the  urethra  and  bladder,  and  this  contraction 
again  causes  pain,  "  the  vicious  circle,"  as  it  is  termed,  being  thus 
established.  In  other  words,  the  cause  produces  an  effect,  which 
in  turn,  acts  as  a  cause  and  aggravates  the  original  disorder. 

Syiwptoinatology . — The  symptoms  of  fissure  are  a  constant  desire 
to  urinate,  and  a  feeling  of  burning  pain  at  the  neck  of  the  bladder. 
There  is  acute  pain  both  during  and  immediately  after  the  act  of 
micturition,  and  severe  tenesmus,  which  causes  the  patient  to  make 
voluntary  straining  efforts  at  evacuation  after  the  bladder  is  empty. 
Immediately  after  urination  the  p)ain  and  burning  are  often  intense. 
After  a  time  it  partially  subsides,  but  again  commences  when  a  lit- 
tle urine  collects  in  the  bladder. 

When  the  patients  resist  the  desire  to  urinate  (as  they  often  do 
at  night  when  unwilling  to  get  up)  the  distress  is  much  aggravated. 
It  will  be  seen  that  all  the  symptoms  mentioned  are  much  the  same 
as  those  presented  in  cystitis,  and  on  that  account  are  not  reliable 
guides  in  diagnosis.  Urethritis  also  gives  rise  to  many  of  the  symp- 
toms named  above,  and  might  be  mistaken  for  urethro-vesical  fissure. 
There  are,  however,  some  points  of  difference  between  the  symptoms 
of  these  three  affections  that  are  deserving  of  notice.  In  fissure  the 
pain  is,  as  a  rule,  more  circumscribed  than  in  either  cystitis  or  ure- 
thritis, and  in  many  cases  more  acute.  Urination  in  fissure  is 
always  followed  by  the  maximum  of  pain,  while  in  cystitis  there  is 
a  slight  sense  of  relief.  In  urethritis  the  greatest  pain  is  experi- 
enced during  the  act  of  urination  ;  it  then  subsides  gradually,  and  is 
usually  absent  before  the  next  evacuation  of  the  bladder. 

Diagnosis. — The  question  of  diagnosis  will  usually  rest  between 
fissure,  urethritis,  and  cystitis.  The  latter  can  be  easily  and  posi- 
tively excluded  by  an  examination  of  the  urine.     Passing  a  catheter 


890  DISEASES  OF  WOMEN. 

into  the  bladder  and  allowing  a  little  urine  to  flow  through  it  will 
wash  away  any  pus  or  mucus  that  may  have  been  caught  up  in  its 
introduction.  The  remaining  urine  should  be  saved  for  examina- 
tion, when  if  Assure  alone  exist,  it  will  be  found  free  from  all  the 
products  of  cystitis. 

The  exclusion  of  urethritis  and  the  detection  of  fissure  are  ac- 
complished by  the  endoscope,  and  by  the  use  of  this  instrument  a 
correct  diagnosis  can  easily  be  made.  I  have  already  described  the 
method  of  using  my  endoscope,  but  there  are  a  few  points  in  the 
examination  for  fissure  to  which  I  have  yet  to  call  attention.  In 
the  first  place,  the  neck  of  the  bladder  must  be  found  exactly,  and 
to  accomplish  this  the  instrument  must  be  used  when  there  is  at 
least  a  small  quantity  of  urine  in  the  organ.  Then  the  tube  is  to  be 
introduced  far  enough  to  be  sure  that  it  enters  the  bladder.  Next 
the  mirror  is  to  be  passed  in,  and,  when  it  enters  that  part  of  the 
tube  surrounded  by  urine,  it  will  be  seen  that  it  becomes  black,  i.  e., 
the  wall  of  the  urethra  (which  was  reflected  as  the  mirror  was  passed 
in)  disappears,  and  nothing  can  be  seen.  By  slowly  withdrawing 
the  mirror  the  upper  end  of  the  urethra  will  come  into  view,  and 
by  moving  it  backward  and  forward  and  turning  it  round,  the  whole 
circumference  of  the  vesico-urethral  juncture  can  be  clearly  seen, 
and  the  fissure  distinctly  observed. 

The  service  rendered  me  by  this  instrument  in  studying  this 
affection  has  been  very  great.  Indeed,  I  was  never  able  to  detect  a 
vesico-urethral  fissure  until  I  used  this  endoscope  to  look  for  it.  I 
have  tried  repeatedly  to  find  a  fissure  with  the  ordinary  open-tube 
endoscope,  and  have  invariably  failed,  and  for  these  reasons  :  Fissure 
lies  in  a  longitudinal  sulcus  of  the  mucous  membrane,  and  is  hidden 
from  view  at  the  upper  or  open  end  of  the  tube.  It  can  only  be 
brought  to  light  by  distending  the  urethra  at  the  point  to  be  ob- 
served, and  that  can  not  be  done  with  the  instrument  in  question. 
Again,  when  the  open  tube  is  carried  up  to  the  neck  of  the  bladder, 
where  the  fissure  is  situated,  the  urine  flows  into  the  tube  and  puts 
a  stop  to  observations. 

The  description  of  the  appearance  of  fissure  already  given  was 
taken  from  my  own  observation  with  the  endoscope,  and,  therefore, 
need  not  be  repeated  here. 

Cmisation. — The  cause  or  causes  of  fissure  here  are  not  well 
understood.  At  least,  I  have  not  been  able  to  find  anything  in  the 
books  that  is  clear  and  definite  on  the  subject. 

From  a  careful  study  of  the  cases  which  have  come  under  my 
own  observation,  I  am  satisfied  that  fissure  (or  irritable  ulcer)  ia 


ORGANIC  DISEASES  OF  THE  URETHRA.  ciQl 

developed  from  urethritis,  I  will  suppose  that  a  woman  gets 
urethritis,  from  any  cause,  and  that  it  extends  to  the  neck  of  the 
bladder,  and  dips  down  into  the  folds  of  the  mucous  membrane.  It 
is  easy  to  understand  that  the  pressing  together  of  the  two  inflamed 
surfaces  of  the  membrane  in  these  folds  will  increase  the  irritation 
and  keep  up  the  disease.  Urine,  mucus,  pus,  and  exfoliated  epithe- 
lium are  liable  to  lodge  in  this  location,  and  add  very  much  to  the 
irritation.  All  this  leads  to  ulceration,  and  when  this  is  established 
it  remains,  with  no  tendency  to  recover.  Even  if  the  parts  were 
inclined  to  heal,  the  irritation  of  the  urine  and  inflammatory  prod- 
ucts, as  well  as  the  contraction  of  the  inflamed  stu^faces  upon  each 
other,  would  prevent,  or  at  least  hinder,  recovery. 

It  can  be  seen  that  an  urethritis  might  end  promptly  in  recovery 
(either  by  the  natural  tendency  of  mucous  inflammation  to  return  to 
health,  or  under  the  influence  of  treatment),  except  at  the  point  of 
fissure,  where  the  conditions  named  tend  to  produce  ulceration,  and 
when  once  developed,  to  keep  it  up. 

Injuries  during  confinement,  displacements  of  the  bladder,  indeed, 
injuries  of  any  kind  that  are  sufiicient  to  cause  inflammation  at  the 
vesico-urethral  juncture,  doubtless  tend  to  the  establishment  of 
fissure. 

Bungling  or  careless  use  of  the  catheter,  or  injections  into  the 
bladder  or  urethra,  might  have  the  same  evil  effects. 

I  suspect,  but  am  not  quite  sure,  that  very  small  calculi  passing 
along  the  urethra  may  be  a  cause  of  this  trouble.  This  supposition 
is  based  on  a  case  which  occurred  in  my  practice.  Its  history  is 
this.  The  lady  had  a  vesico-vaginal  fistula,  and  after  it  was  closed 
she  had  catarrh  of  the  bladder.  During  the  course  of  that  disease 
she  was  taken  with  hgemorrhage,  which  lasted  some  days.  She  then 
had  violent  pain  in  urinating,  and  passed  several  lumps  which  were 
composed  of  mucus  and  some  of  the  salts  of  the  urine.  These  pieces 
were  rough,  gritty  masses,  which  no  doubt  scratched  the  urethra  as 
they  passed  out.  Soon  after  this  she  was  found  to  have  a  fissure 
that  tormented  her  to  an  extent  beyond  description.  Dilatation  of 
the  urethra  and  topical  apphcations  relieved  her. 

Treatment. — The  subject  of  the  management  of  vesico-urethral 
fissure  is  one  of  interest  and  importance,  as  much  so  as  anything  in 
surgery.  On  the  one  hand  there  is  the  terrible  suffering  of  the 
patient,  and  on  the  other  there  are  many  difficulties  to  be  encoun- 
tered in  the  efforts  to  relieve  her.  The  demand  for  treatment  is 
urgent,  and  skill  in  the  highest  degree  is  necessary  to  accomplish  a 
cure. 


892  DISEASES  OF  WOMEN. 

I  must  first  say  wliat  ouglit  not  to  be  done  in  tliese  cases,  and 
thereby  guard  against  making  them  worse  instead  of  better,  as  it  has 
been  my  misfortune  to  do  on  more  than  one  occasion.  As  a  rule, 
all  injections  and  instillations  such  as  I  have  recommended  in  cys- 
titis, and  shall  advise  in  urethritis,  do  harm  in  fissure.  I  have  used 
injections  of  mild  solutions  of  nitrate  of  silver,  and  the  application 
of  stronger  solutions  to  the  diseased  part,  with  the  invariable  result 
of  increasing  the  spasmodic  contraction  of  the  bladder  and  aggrava- 
ting the  suffering  of  my  patients. 

While  such  applications  are  useful  in  inflammation  of  the  bladder 
and  urethra  they  do  harm  in  fissure.  This  I  have  repeatedly  proved 
to  my  own  satisfaction,  and  the  facts  accord  with  our  experience  in 
other  departments  of  practice.  Nitrate  of  silver  and  nitric  acid  have 
been  applied  to  ulcerations  of  the  rectum  with  marked  benefit,  and 
without  being  followed  by  pain  of  any  account ;  but  the  same  appli- 
cation made  to  fissure  within  the  grasp  of  the  sphincter  ani  does 
little  if  any  good,  and  usually  increases  the  suffering  of  the  patient. 
The  same  is  true  of  the  fissure  under  discussion.  When  a  diagnosis 
of  vesico-urethral  fissure  has  been  made,  the  usual  local  treatment  is 
not  to  be  employed,  at  least  active  measures  in  the  way  of  powerful 
applications  are  to  be  avoided. 

Soothing  applications,  alterative  in  their  action,  are  worthy  of 
trial.  Exposing  the  fissure  with  the  fenestrated  speculum,  and 
dusting  it  over  with  calomel  or  finely  pulverized  iodoform,  some- 
times give  relief.  Subnitrate  of  bismuth  may  be  used  in  the  same 
way  in  the  hope  of  doing  good.  There  is  one  great  point  to  be 
remembered  in  using  these  remedies,  and  that  is,  that  if  they  fail  to 
accomplish  the  desired  end,  they  do  no  harm. 

I  have  used  with  benefit  the  "mitigated"  stick  of  nitrate  of 
silver.  It  consists  of  one  part  of  nitrate  of  silver  to  two  or  three 
parts  of  the  nitrate  of  potash.  Drawing  a  fine  point  of  this  through 
the  fissure  causes  sharp  ]3ain  at  the  time,  which  is  often  followed  by 
burning,  and  tenesmus,  which,  however,  soon  subside.  In  some 
cases  the  trouble  is  relieved  by  this  treatment. 

Incising  the  fissure,  in  the  manner  that  surgeons  treat  the  same 
disease   of   the   anus, 
has  been  followed  by    ^^'^^^'^^Z^::=,======^^^^^ 

great  relief,  but  I  do 

not  believe  that  I  ever  p^^  272.-Skcne's  fissure  probe  and  knife, 

cured   a  case   in    this 

way.     For  this  operation  I  use  a  small  knife,  which  is  represented 
in  P'ig.  272. 


ORGANIC  DISEASES  OF  THE  URETHRA.  893 

In  the  employment  of  this  local  treatment  great  difficulty  will  be 
found  in  getting  at  the  diseased  spot.  The  fissure  can  easily  Ije  seen 
through  the  glass  tube  of  the  endoscope,  but  to  expose  it  and  make 
applications  to  it  are  exceedingly  difficult  tasks.  I  have  tried  in  a 
variety  of  ways  to  do  this,  but  have  found  that  the  only  satisfactory 
way  is  by  means  of  the  endoscope,  consisting  of  a  glass  tube,  hard- 
rubber  external  tube,  and  mirror,  which  I  have  fully  described.  This 
combination  of  speculum  and  mirror  answers  very  well  in  applying 
such  remedies  as  bismuth,  calomel,  and  the  like ;  but  it  will  be  found 
that  skill  and  patience  are  required  to  touch  the  fissure  with  the 
nitrate-of -silver  stick,  or  to  incise  the  part  as  already  advised. 

The  method  which  I  employ  is  this :  A  small  silver  probe  is  bent 
into  the  shape  shown  in  the  figure  (Fig.  272),  and  its  point  is  coated 
with  the  material  to  be  used.  It  is  then  introduced  tlirough  the 
speculum  and  drawn  slowly  through  the  fissure  so  as  to  produce 
superficial  cauterization  of  the  ulcerated  part.  The  point  of  the 
probe  is  coated  by  melting  the  "  mitigated  "  stick  of  nitrate  of  silver 
in  a  platinum  cup,  into  which  the  probe  is  dipped  and  the  coating 
allowed  to  cool.  The  dipping  may  be  repeated  as  often  as  is  neces- 
sary to  get  the  required  amount  of  caustic  or  coating  on  the  probe. 

Before  applying  the  caustic,  any  mucus  or  serum  that  may  be  in 
or  about  the  fissure  must  be  sponged  away.  This  may  be  done  by 
wrapping  a  piece  of  absorbent  cotton  on  the  end  of  a  probe,  and 
using  it  as  a  sponge. 

It  will  be  observed  that  I  condemned  caustics  in  the  treatment 
of  fissure,  and  still  advise  cauterizing  the  diseased  part  with  nitrate 
of  silver.  The  point  is  simply  this,  that  caustics  applied  by  injec- 
tion to  the  neck  of  the  bladder  in  which  there  is  fissure  do  harm, 
but  caustic  appHed  to  the  fissure  only,  does  good. 

I  have  observed  that  pain  follows  the  application  of  caustics,  but 
if  the  diseased  portion  and  nothing  more  is  thoroughly  touched,  re- 
lief follows.  The  old  trouble  and  pain  are,  however,  liable  to  return 
in  time.  The  same  may  be  said  of  incision,  viz.,  that  relief  is  but 
temporary.  I  think  that  the  bleeding  which  is  caused  relieves  irri- 
tation and  congestion  for  a  time,  but  I  can  not  say  that  I  have  ever 
seen  a  permanent  cure  follow  this  treatment,  except  in  a  few  cases, 
where  the  treatment  was  begun  early  in  the  course  of  the  disease. 

I  come  now  to  dilatation  of  the  urethra  as  a  means  of  relieving 
fissure.  Although  I  have  left  this  measure  until  the  last,  it  is  really 
the  first  in  importance  in  the  treatment  of  this  affection.  Indeed, 
I  am  inclined  to  think  that  it  is  of  much  more  value  in  the  treat- 
ment of  fissure  than  in  that  of  either  cystitis  or  urethritis. 


894  DISEASES  OF  WOMEN. 

I  have  already  sounded  a  note  of  warning  against  the  two  great 
dangers  of  dilating  the  urethra — viz.,  rupture  and  incontinence,  and 
incontinence  without  rupture.  Both  accidents  are  liable  to  occur  in 
dilating  the  uretlira,  but  they  only  occur  when  the  dilatation  is 
carried  to  a  great  extent,  sufficient  at  least,  to  admit  the  ordinary 
sized  index-finger.  This  extreme  dilatation  is  not  necessary  in  the 
treatment  of  fissure.  I  generally  ascertain  what  sized  sound  can  be 
passed  with  ease,  and  then  dilate  sufficiently  to  admit  one  three 
or  four  sizes  larger.     Tliis  is  usually  all  that  is  necessary. 

Before  dilating  it  must  be  seen  that  the  urine  is  normal  in  char- 
acter, or  as  nearly  so  as  can  be  made  by  general  treatment.  Then 
the  urethra  is  to  be  dilated,  the  patient  being  kept  at  rest,  and  the 
urine  made  as  bland  as  possible  with  diluent  drinks. 

In  case  that  incontinence  should  follow  (though  I  presume  that 
will  not  occur),  its  treatment  should  at  once  be  commenced  by  sup- 
porting the  urethra  in  the  way  that  I  have  advised,  viz.,  with  the 
pessary  for  that  purpose.  I  believe  that,  if  taken  in  hand  within 
three  or  four  days  after  it  occurs,  the  incontinence  can  be  relieved. 

Should  the  treatment  that  I  have  thus  far  recommended  fail, 
then  a  vesico-vaginal  fistula  should  be  made,  the  bladder  and  urethra 
washed  out  regularly,  and  if  need  be  medicated.  The  fistula  may 
be  allowed  to  close  of  its  own  accord,  as  it  usually  will  do.  By  the 
time  the  fistula  closes,  the  fissure  will  have  healed.  In  making  a 
vesico-vaginal  fistula  to  cure  fissure,  the  knife  or  scissors  should  be 
used,  and  not  the  cautery ;  because  it  is  not  necessary  to  maintain 
the  opening  in  the  bladder  for  a  very  long  time  :  and  if  it  closes  of 
its  own  accord,  a  very  important  operation  is  avoided. 

4.  Neoplasms  of  the  Urethra. — A  knowledge  of  urethral  neo- 
plasms is  by  no  means  confined  to  recent  times,  but  up  to  a  late 
date  they  have  not  been  studied  as  closely  as  they  deserve  to  be,  nor 
classified  in  a  comprehensive  and  scientific  manner.  The  various 
tumors  have  frequently  been  confounded  with  one  another  by 
authors  and  observers,  and  much  confusion  and  obscure  statement 
have  resulted  in  regard  to  their  symptomatology,  pathology,  and 
treatment. 

These  grow'ths  have  been  variously  known  as  carunculse,  cellulo- 
vascular  tumors,  fleshy  and  vascular  growths,  fungoid  excrescences, 
strasvberry  and  raspberry  tumors,  each  name  sometimes  having 
been  used  to  cover  the  whole  class. 

"VVinckel's  division  and  classification  are  most  excellent,  and  to 
some  extent  I  shall  follow  them  in  the  consideration  of  the  subject. 
I  will  classify  these  tumors  as  follows : 


ORGANIC   DISEASES  OP  THE  URETHRA.  895 

Papillary. — Condyloma. 

Glandular. — Cysts,  myxo-adenoma,  mucous  polypi. 

Vascular. — Angioma,  varices,  phlebectases. 

Areolar  Connective  Tissue. — Fibroma,  sarcoma. 

Epitlielial. — Epithelioma,  carcinoma. 

Compound. — Papillary  polypoid  angioma,  erectile  tumors. 

Neoplasms  of  the  urethra  are  more  common  in  the  female  than 
in  the  male,  and,  of  course,  easier  of  diagnosis  and  treatment. 

Papillary  Neoplasms. — Under  the  first  head,  or  that  of  papillary 
neoplasms,  will  be  seen  condyloma,  a  growth  of  a  low  grade,  and  of 
a  warty  appearance.  The  surface  may  be  bright  red,  or  partially 
white,  from  epithelial  aggregation.  These  growths  are  painless,  and 
do  not  bleed  on  touch  or  manipulation.  They  may  or  may  not  be 
pedunculated.  They  may  occur  singly  or  in  clusters,  and  be  wholly 
within  the  urethra  or  projecting  from  the  meatus. 

They  consist  of  somewhat  dilated  capillaries  set  in  a  tough  homo- 
geneous network  of  connective  tissue,  the  whole  having  a  thin  epi- 
thelial covering,  that  may  at  times  be  increased  by  an  unusually 
rapid  epithelial  proliferation.  This  only  occurs  when  the  tumors 
are  much  irritated. 

Glandular  Neoplasms. — Cysts  of  the  female  urethra  are  not  com- 
mon, and  are  not  confined  to  any  period  of  life,  having  been  found 
in  a  foetus  of  from  six  to  seven  months  and  in  all  subsequent  periods 
of  life. 

They  are  in  early  age  situated  in  the  anterior  or  meatal  portion 
of  the  urethra,  but  later  in  life  nearer  the  vesical  neck.  They  may 
or  may  not  project  from  the  urethra ;  however,  they  cause  a  greater 
or  less  obstruction  to  the  free  outfiow  of  urine.  They  are  usually 
formed  by  the  occlusion  of  the  orifice  of  the  small  urethral  ducts 
or  glands,  and,  in  some  cases,  a  black  speck  upon  the  surface  of  the 
cyst  indicates  the  seat  of  the  former  orifice. 

By  bagging  of  the  mucous  membrane  and  absorption  of  the  con- 
tents, these  small  cysts  may  be  transformed  into  polypi. 

Winckel  says  that  the  internal  wall  of  the  cyst  usually  shows 
numerous  small  papillge,  and  is  lined  with  pavement  epithelial  scales. 

Myxo-adenoma  are  quite  rare.  They  are  small  (the  largest  being 
seldom  larger  than  a  small  hazel-nut),  of  a  bright  scarlet  color,  and 
quite  vascular.  They  consist  of  a  number  of  vessels  set  in  partly 
destroyed  gland  tissue,  and  small  meshes  containing  myxomatous 
matter.  The  whole  is  contained  in  the  meshes  of  a  soft,  loose  con- 
nective tissue. 

Polypi  coming  under  this  head  are  those  formed  by  occlusion  of 


896  DISEASES  OF  WOMEN. 

the  orifices  of  one  or  more  of  the  ducts  or  follicles  of  the  urethra. 
The  other  forms  of  polypi  will  be  considered  under  their  proper 
head. 

Vascular  Neoplasms. — Angioma,  varices,  and  phlebectases  are 
really  different  names  for  about  the  same  condition — viz.,  an  increase 
in  the  caliber  of  the  veins  and  venous  radicles,  allowing  an  overdis- 
tention,  at  first  intermittent,  and  later  chronic.  They  appear  as 
bunches  or  bundles  of  worm-like,  irregularly  distended  dark  blue 
or  bluish  red  vessels.  There  is  more  or  less  thickening  of  the  mucous 
membrane  and  connective  tissue  about  them ;  they  are,  in  fact,  in 
all  respects  analogous  to  rectal  haemorrhoids.  They  may  occupy  any 
part  of  the  urethra,  but  usually  select  the  floor  of  the  canal.  The 
trouble  they  cause  depends  on  their  size.  If  large,  they  obstruct  the 
urethra.  Sometimes  the  vessels  rupture,  and  the  blood  is  poured  out 
beneath  the  mucous  membrane.  Tumors  resulting  from  rupture  of 
such  varices  under  a  normal  mucous  membrane  have  been  known  to 
some  authors  under  the  name  of  hsematoma  polyposum  urethrse, 
which  describes  very  well  the  condition  resulting. 

Some  of  these  vascular  tumors  have  been  found  to  be  erectile, 
the  anatomical  peculiarities  of  which  structure  are  already  familiar. 

Virchow  believes  these  tumors  to  be  a  combination  of  urethral 
haemorrhoids  and  remnants  of  embryonal  duplicity  of  the  vagina. 

Areolar  Neoplasms. — Tliese  new  growths  are  either  fibromata  or 
sarcomata. 

The  fibromata  may  lie  within  the  canal  of  the  urethra  or  be  im- 
bedded in  its  walls.  When  in  the  urethra  or  protruding  from  the 
meatus,  they  are  pedunculated,  and  have  been  known  as  urethral 
polypi.  They  vary  in  size  from  that  of  a  pea  to  that  of  a  goose-egg. 
They  consist  of  numerous  densely  packed  fibers,  that  give  the  same 
appearances  as  fibromata  elsewhere. 

They  have  been  found  in  several  cases  at  birth,  but  are  of  rare 
occurrence  at  any  age.  When  congenital,  they  have  been  known  as 
congenital  polypoid  excrescences.  The  tumors  are  usually  covered 
with  several  layers  of  pavement  epithelium. 

Sarcoma  of  the  urethra  is  an  extremely  rare  affection,  but  one  or 
two  cases  being  on  record.  One  case  observed  by  Beigel  is  described 
by  Winckel.  It  was  trilobed,  about  the  size  of  a  walnut,  and  was 
situated  about  the  edge  of  the  external  meatus.  It  was  in  part  hard, 
in  part  soft,  the  harder  portion  consisting  of  a  fine  fibrous  network, 
the  interstices  of  which  were  filled  with  small  cells.  In  some  places 
the  cells  were  absent  and  the  stroma  more  dense,  and  in  the  pe- 
ripheral jjarts  the  network,  while  coarser,  was  firm,  and  presented 


ORGANIC   DISEASES  OF  TUB    URETHRA.  S97 

3avities  filled  with  a  colloid  material.  Tlie  tumor  was  extirpated, 
but  uotliiug  is  said  about  its  return. 

Epithelial  Neoplasms. — The  existence  of  cancerous  disease  of  the 
female  urethra  as  a  primary  affection  is  greatly  doubted  Ijy  many 
authors,  but  it  probably  does  occasionally  occur.  Indeed,  as  a  sec- 
ondary disease,  it  is  quite  rare,  for,  when  extending  from  the  uterus 
or  neighboring  organs  to  the  bladder,  death,  as  a  rule,  results  before 
the  urethra  is  involved.  In  cases  where  hfe  is  unusually  prolonged, 
the  disease  seldom  attacks  more  than  the  vesical  portion  of  the  canal. 

Extension  from  the  outer  genitals,  which  are  very  rarely  affected 
with  cancerous  disease,  is  still  more  uncommon,  and  possibly  has 
never  occurred.  One  case  is  recorded,  however,  in  a  woman  who 
had  long  suffered  from  uterine  prolapse,  where  a  tumor,  which  de- 
pended from  the  fraeniculum  clitoridis,  had  invaded  the  meatus 
urinarius.  Under  the  microscope  it  proved  to  be  a  flat-celled  epi- 
thelio-cancroid. 

We  have  the  record  of  cases  of  periurethral  cancer  that  ap- 
peared at  the  introitus  vulvae  near  the  meatus,  and  in  the  connective 
tissue  about  the  urethra,  as  small,  hard,  painless  tubercles,  the  ure- 
thra or  its  membrane  not  being  involved. 

Symptomatology. — Pain  is  the  exception  rather  than  the  rule  in 
this  affection ;  but  in  some  instances  acute,  lancinating  pains  are  pres- 
ent. At  first  the  tubercles  are  small,  hard,  and  usually  painless,  but 
after  a  time  they  soften,  ulcerate,  and  bleed  freely.  The  vesti- 
bule and  urethral  mucous  membrane  are  usually  involved  in  the 
mischief. 

The  affection  has  been  divided  into  three  grades,  in  the  first  of 
which,  according  to  Winckel,  "  but  half  the  length  and  depth  of  the 
urethra  is  invaded  by  the  cancerous  tubercles ;  in  the  second  the 
vesical  neck  and  pelvic  fascia;  and  in  the  third  the  pubic  sym- 
physis, descending  pubic  rami,  and  the  closely  blended  connective 
tissue  are  involved." 

Compound  Neoplasms. — The  most  common,  and  consequently  the 
most  interesting  form  of  urethral  neoplasm,  is  the  papillary  polypoid 
angioma. 

These  tumors  vary  in  size  from  a  pin-head  to  a  hickory-nut,  and 
may  be  either  multiple  or  single,  but  are  usually  single.  They  vary 
in  color  from  a  pale  to  a  bright  red,  and  may  or  may  not  be  pedun- 
culated. Their  favorite  seat  is  on  the  posterior  wall  of  the  lower 
half  of  the  urethra,  very  near  to  or  at  the  meatus.  This  neoplasm 
is  generally  known  as  urethral  caruncle,  or  vascular  tumor  of  the 
urethra,  and  is  described  very  fully  in  most  of  the  books  on  diseases 
68 


898  DISEASES  OF  WOMEN. 

of  women.  Indeed,  it  is  the  only  abnormal  growth  of  the  female 
urethra  that  I  ever  read  or  heard  of  in  my  student  days.  There  is 
really  not  much  difference  between  this  form  of  neoplasm  and  the 
vascular  tumor  of  the  urethra  already  described,  and  what  is  far  more 
important  both  of  these  neoplasms  have  been  confounded  with  hyper- 
plasia of  the  tissues  around  the  mouths  of  the  ducts  of  the  urethral 
glands.  This  condition  will  be  discussed  under  the  head  of  diseases 
of  the  urethral  glands.  There  are  very  good  reasons  why  this  affection 
should  have  claimed  early  attention  from  gynecologists.  It  occurs 
frequently,  and  nearly  always  causes  great  suffering,  and  is  easily 
detected,  because  it  grows  at  the  meatus  urinarius,  where  it  can  be 
seen. 

It  consists  of  bunches  of  dilated  capillaries  set  in  a  moderately 
dense  stroma  of  connective  tissue,  and  covered  with  mucous  mem- 
brane, which  has  the  usual  pavement  ej)ithelium.  One  case,  however^ 
is  recorded  where  the  pavement  was  replaced  by  columnar  epithe- 
lium. The  vessels  are  greatly  dilated,  and  in  some  cases  very  tor- 
tuous ;  in  others  much  less  so. 

In  some  cases  these  tumors  partake  of  the  erectile  character, 
being  markedly  increased  in  size  at  the  menstrual  period,  and  at 
other  times. 

Occasionally  small  tumors  .of  this  kind  are  found  singly  in  the 
vestibule.  As  a  rule  they  bleed  very  easily  on  touch,  and  are  ex- 
quisitely sensitive.  Observers  differ  as  to  whether  the  nerve  supply 
to  the  tumor  is  marked,  some  claiming  to  find  a  large  nerve  distri- 
bution, others  to  find  none.  As  they  are  exceedingly  tender,  the 
inference  may  be  drawn  that  they  are  well  supplied  with  nerves. 

Symptomatology. — Unless  the  tumors  be  of  large  size  the  patient 
may  go  on  for  a  long  period  without  experiencing  anything  more 
than  a  slightly  irritable  condition  of  the  urethra.  When,  however, 
the  tumors  become  large,  or  are  of  the  polypoid  angioma  variety,  the 
pain  is  markedly  increased,  and  the  obstruction  to  the  outflow  of 
urine  becomes  very  apparent.  These  tumors,  by  constant  moisture 
and  friction,  become  eroded  on  their  surface,  and  these  ulcerations, 
being  constantly  aggravated,  give  rise  usually  to  slight  hemorrhage 
and  increased  pain.  Retention  of  urine  may  result  from  their  clos- 
ing the  urethra. 

Of  all  the  urethral  neoplasms,  however,  the  papillary  polypoid 
angiomata  are  the  most  intensely  painful,  and  patients  retain  their 
water  for  a  long  time  to  avoid  the  agony  that  is  produced  by  passing 
it.  The  pain  is,  in  some  cases,  present  at  all  times,  and  is  greatly 
aggravated  by  sitting  or  lying  down.     The  clothes  coming  in  con- 


ORGANIC   DISEASES  OF  THE  URETHRA.  899 

tact  witli  the  exquisitely  sensitive  surface  often  produce  vaginal  and 
anal  spasm.  Coition  is  sometimes  impossible.  A  case  is  related  of 
an  old  woman  thus  affected,  who,  though  married  some  thirty  years, 
was  still  a  virgin.  Indeed,  this  affection  is  sometimes  mistaken  for 
vaginismus,  and  treated  accordingly.  The  directions  which  I  shall 
give  under  the  head  of  diagnosis  will,  I  think,  be  sufficiently  plain 
to  prevent  such  mistakes. 

Even  when  these  tumors  are  too  small  to  obstruct  the  urethra, 
obstruction  may  occur  from  severe  spasm  due  to  the  pain  caused  in 
the  act  of  micturition. 

Bleeding  from  these  tumors  is  not  uncommon,  but  it  seldom 
amounts  to  much,  and  is  easily  controlled. 

The  pain  in  any  of  these  new  growths  is  not  always  confined  to 
the  urethra,  but  may  be  felt  in  the  back,  hips,  suj)rapubic  region, 
thighs,  knees,  and  feet.  In  carcinoma  lancinating  pains  may  be 
present,  but  this  is  by  no  means  the  rule. 

As  the  tumors  increase  in  size,  the  urethra  becomes  gradually 
dilated,  and  the  mucous  membrane  eroded,  h3rper8emic,  and  catarrhal. 
Its  structure  may  become  loose,  flabby,  and  vascular,  and  a  pouch 
form  behind  the  tumor.  If  far  enough  back  to  interfere  with  per- 
fect closure  of  the  vesical  neck,  incontinence  may  occur,  and  incon- 
venience and  distress  the  patient  greatly. 

Sometimes  the  bleeding  is  severe,  and  the  patient  suffers  from 
anaemia  caused  thereby.  This  is  more  usually  the  case  if,  in  the  de- 
structive process  attending  carcinoma,  an  artery  of  any  considerable 
size  is  opened  into.     This  accident,  however,  rarely  occurs. 

In  the  extremely  painful  neoplasms,  the  face  gives  evidence  of 
constant  pain,  distress,  and  anxiety ;  and  in  the  most  aggravated 
forms  patients  are  pale,  emaciated,  and  extremely  low-spirited,  often 
wishing  earnestly  for  death  to  relieve  their  sufferings. 

If  the  tumor  be  of  sufficient  size  to  be  a  serious  bar  to  free  mic- 
turition, cystitis,  pyelitis,  and  more  serious  results,  as  renal  destruc- 
tion, are  to  be  feared. 

The  presence  of  small,  and  even  large  tumors,  in  the  urethra 
and  about  the  meatus  often  gives  rise  to  increased  sexual  desire,  that 
is  gratified  in  the  young  girl  by  masturbation. 

The  urine  is  normal,  save  that  it  contains  the  products  of  urethral 
disease,  viz.,  epithelium,  pus,  mucus,  and  sometimes  blood.  Small 
pieces  of  the  tumor,  small  cysts  or  polypi,  the  pedicles  of  which 
have  died  or  been  torn  through,  are  sometimes  found  in  the  urine. 

In  cancerous  neoplasms,  as  the  disease  invades  the  tissues  to  the 
second  and  third  degrees  mentioned  in  connection  with  malignant 


900  DISEASES  OF  WOMEN. 

tubercle,  the  patients  gradually  sink  and  die  from  exhaustion  from 
severe  bleedings,  loss  of  rest,  and  general  cachexia.  Soine  cases, 
however,  do  not  succumb  until  long  after  the  third  degree  has  been 
reached,  with  extensive  destruction  of  tissue. 

Diagnosis. — The  diagnosis  of  urethral  neoplasm  is  really  quite 
easy,  provided  the  investigation  is  thoroughly  and  intelligently  con- 
ducted. When  a  woman  comes  to  the  physician  complaining  of 
pain  on  micturition,  pain  in  sitting,  obstructions  to  or  interruptions 
in  the  flow  of  urine  he  should  at  once  proceed  to  a  thorough  investi- 
gation of  the  parts,  first  by  the  eye  and  touch,  and  second  by  the 
aid  of  the  speculum,  endoscope,  and  an  examination  of  the  urine. 
If  the  tumor  presents  at  the  meatus,  it  will,  of  course,  be  readily 
seen,  and  can  be  easily  diagnosticated. 

If  in  the  urethra,  the  finger  passed  along  the  course  of  the  ure- 
thra in  the  vagina,  with  some  dilatation  of  the  meatus,  will  discover 
it.  If  of  small  size,  the  endoscope,  with  a  strong  light,  will  give  an 
excellent  view  of  it.  If  the  tumor  be  exquisitely  sensitive,  as 
some  are,  the  patient  should  be  wholly  or  partially  anaesthetized,  and 
then  the  examination  can  be  fully  and  freely  made.  Vaginismus 
may  be  excluded  by  passing  the  finger  into  the  vagina,  away  from 
the  urethra,  when  no  spasm  will  take  place ;  but  if  the  urethra  is 
touched,  the  spasm  is  at  once  produced. 

To  determine  whether  the  inflammatory  mischief,  when  it  exists, 
resides  in  the  urethra  alone,  the  patient  should  be  directed  to  pass 
one  half  of  her  urine  into  one  vessel,  and  the  other  into  another.  If 
the  trouble  is  seated  in  the  urethra  only,  the  last  urine  passed  will  be 
totally  or  almost  wholly  free  from  the  inflammatory  products.  The 
same  may  be  accomplished  also  by  drawing  off  the  urine  with  a 
clean  catheter. 

In  some  cases  the  varicose  condition  of  the  vessels  of  the  nmcous 
membrane,  with  considerable  swelling,  may  simulate  prolapse  of  the 
mucous  membrane.  If,  however,  the  blue  discoloration  is  borne  in 
mind  together  with  the  elastic  feel,  and  the  reduction  in  size  under 
compression  of  the  urethral  haemorrhoids,  there  will  seldom  be  any 
error  in  the  diagnosis.  Of  course,  prolapse  of  the  mucous  membrane 
and  a  varicose  condition  of  the  urethral  veins  sometimes  coexist,  and 
this  must  not  be  forgotten. 

Tumors,  usually  those  of  large  size  and  pedunculated,  often  cause 
gome  degree  of  pi'olapse  of  the  mucous  membrane  by  constant  drag- 
ging. A  prolapsus  of  the  mucous  membrane  may  also  simulate  a 
tumor.  The  position  of  the  meatal  orifice,  and  the  fact  that  it  can 
be  reduced,  will  distinguish  the  prolapse. 


ORGANIC   DISEASES   OF   THE   URETHRA.  QQl 

To  distinguish  one  kind  of  tumor  from  another  is  not  always 
easy,  but  with  a  little  care  it  can  be  accomplisiied.  The  condyloma 
will  ])e  recognized  by  its  painlessness,  its  warty,  cracked,  pinkish 
white  or  white  surface,  and  the  fact  that  similar  growths  are  at  the 
same  time  usually  found  on  the  vestibule.  The  polypoid  angioma 
will  be  known  by  its  bright-red  surface,  its  tendency  to  bleed 
easily,  and  the  exquisite  pain  produced  when  touched.  The  sar- 
coma will  be  readily  confounded  with  the  angioma,  but  it  is  very 
rarely  found  here ;  and  if  there  is  any  doubt,  a  little  piece  may 
be  scraped  off  with  the  curette,  and  examined  microscopically. 
Should  doubt  still  remain,  the  history  and  progress  of  the  disease 
will  soon  determine  the  nature  of  the  trouble.  The  malignant  tumor 
will  grow  much  faster  than  the  other.  The  varices  can  be  told  by 
their  bluish  color  and  their  shrinking  under  pressure,  and  the  cysts 
and  fibromata  by  their  smooth,  painless  surface,  normal  mucous  cov- 
ering, and  their  consistence. 

Carcinoma  appears,  as  I  have  already  said,  as  hard  tubercles 
(usually  periurethral),  which  after  a  time  break  down.  When  this 
occurs,  the  endoscope,  the  lancinating  pains  (if  present),  the  rapid 
invasion  of  neighboring  tissue,  and  the  composition  of  the  diseased 
mass,  under  the  microscope,  will  tell  the  story. 

Prognosis. — The  simple  forms  of  urethral  tumor  are  easily 
removed,  and  do  not  return.  As  a  rule,  therefore,  the  prognosis 
is  good.  Of  this  class  are  cysts,  condylomata,  mucous  polypi,  and 
fibromata. 

The  angiomas  are  of  a  more  serious  nature,  as  by  the  pain  and 
suffering  which  they  cause  the  constitutional  condition  is  usually  low ; 
and,  though  they  may  be  extirpated,  they  are  likely  to  return  and 
rapidly  increase  in  size,  even  in  from  one  to  three  months'  time. 
Although  the  bleeding  from  these  tumors  is  rarely  very  great,  still 
there  may  be  numerous  small  hsemorrhages,  and  at  times  severe 
ones,  either  from  the  urethra  externally  or  into  the  bladder.  Under 
proper  treatment,  however,  there  is  always  a  possibility,  and  in  some 
cases,  a  certainty  of  cure. 

In  carcinoma  there  is  no  hope  of  effecting  a  cure,  although  the 
patient's  condition  may  be  much  improved  in  some  cases.  Death 
usually  ensues  before  the  third  degree  is  reached.  Almost  the  same 
may  be  said  of  epithelioma,  unless  it  is  treated  in  its  early  stages. 

Causation. — The  causes  of  the  various  neoplasms  are  not  yet 
clearly  made  out,  and  will  not  be,  I  think,  until  more  extended  ob- 
servations are  made  on  the  subject.  Even  then  it  is  more  than 
probable  that  some  of  them  will  remain  obscure. 


902  DISEASES  OF   WOMEN. 

The  predisposing  causes  are  a  laxity  of  the  urethral  tissues,  with 
a  tendency  to  a  varicose  condition  of  the  parts,  usually  found  in  old 
age  ;  a  general  tendency  to  venous  stagnation,  catarrh  of  the  mucous 
membrane,  and  dislocation  of  the  urethra,  partial  or  complete. 

As  a  proof  that  no  single  special  cause  produces  these  condi- 
tions, it  may  be  said  that  these  growths  have  been  found  congeni- 
tally,  and  at  every  period  during  life,  as  late  indeed  as  the  ninety-sec- 
ond year. 

The  exciting  causes,  as  given  by  different  authors,  vary.  The 
following  are  some  of  those  usually  mentioned : 

1.  Temporary  or  chronic  congestion  of  the  urethra  during  preg- 
nancy, uterine  and  ovarian  tumors,  and  obstructed  portal  circulation. 

2.  Injuries  to  the  parts  during  labor,  external  violence,  the  irri- 
tation of  chronic  and  acute  urethritis  (specific  or  simple),  syphilitic 
poison,  and  masturbation. 

Of  course,  the  carcinomata,  cysts,  and  simple  mucous  polypi,  are 
not  here  included,  although  some  of  the  above  causes  might  aggra- 
vate if  not  produce  them,  for  I  have  already  spoken  of  their  method 
of  causation  as  far  as  it  is  known.  Cancer  occurs  by  extension  of  the 
disease  from  other  parts ;  cysts  and  mucous  polypi,  from  occluded 
duct  orifices.  This  narrows  the  list  to  the  nervous  class  and  the 
compound,  viz.,  the  polypoid  angiomas.  And  of  these  I  may  vent- 
ure to  say  that  any  cause,  such  as  constant  irritation,  sudden  injury, 
or  slow  congestion,  may  produce  these  conditions,  especially  in 
those  who  are  somewhat  predisposed  ;  but  that  any  one  cause,  such 
as  the  gonorrhoeal  poison,  is  sufficient  to  produce  them,  in  all  cases, 
is  more  than  doubtful. 

Most  of  these  tumors  occur  in  married  women,  both  in  those 
who  have  borne  children  and  in  those  who  have  not. 

It  might  be  supposed  from  all  that  has  been  said  upon  this  sub- 
ject that  urethral  neoplasms  are  very  common.  On  the  contrary, 
they  are  very  rare,  with  the  exception  of  polypoid  angiomas. 

Treatment. — The  treatment  of  these  cases  is,  in  most  instances, 
entirely  surgical,  but  when  the  general  system  is  deranged  in  any 
way  it  should  receive  careful  attention.  If  there  is  a  congested 
condition  of  the  urethra,  the  portal  circulation  should  be  kept  in  a 
normal  state  by  securing  a  healthy  action  of  the  liver  and  bowels. 
The  condition  of  the  circulation  in  the  part  involved  may  possibly 
be  influenced  by  constitutional  medication.  For  this  purpose, 
ergot,  digitalis,  and  nux  vomica,  in  small  doses  regularly  repeated, 
may  be  of  service.  These  remedies  will  at  least  aid  in  securing  a 
good  general  circulation,  and  may  influence  favorably  the  local  affec- 


ORGANIC   DISEASES   OF  THE   URETHRA. 


903 


Fig.  273. — Skene's  urethral  speculum. 


tion.  If  there  is  local  congestion  due  to  pressure  on  the  pelvic  ves- 
sels, the  cause,  interfering  with  the  return  circulation,  should  be 
removed,  or  remedied,  if  possible. 

The  local  treatment  recommended  by  the  various  authors  differs 
widely,  but  has  tlie  same  end  in  view,  viz.,  destruction  or  removal 
of  the  abnormal  growth.  The  various  methods  of  extirpation  em- 
ployed are  ligation,  torsion,  excision  by  the  knife,  scissors,  curette, 
ecraseur,  galvano-cautery,  caustics,  and  electrolysis.  Any  one  of 
these  methods  may  be  made  to  answer  in  all  cases,  but  a  judicious 
selection,  according  to  the  location  and  nature  of  the  neoplasm,  is 
advisable.  A  combination  of  means  is  best  at  times,  as,  for  in- 
stance, excision  by  the  scissors  and  cauterization  afterward. 

Whatever  method  may  be  chosen  the  patient  should  first  be 
placed  in  the  lithotomy  or  in  Sims's  position,  on  the  left  side,  which 
I  prefer,  and  the  part  to  be  removed  exposed  by  a  speculum. 

There  are  two  instruments  which  I  use  for  this  purpose.     The 

first  is  here  shown.  Fig. 
273.  It  is  made  on  the 
principle  of  Sims's  specu- 
lum, the  ends  being  of  dif- 
ferent sizes.  An  elevator 
is  attached  at  the  central  portion  between  the  blades,  and  so  arranged 
that  when  it  is  closed  on  one  blade  it  is  thrown  out  from  the  other. 
This  is  seen  in  the  figure.  The  elevator  is  pressed  down  on  the 
blade,  and  the  instrument  introduced,  and  then  by  pressing  on  the 
other  end  of  the  elevator  the  urethra  is  distended  to  its  full  natural 
capacity.  When  it  is  necessary  to  expose  one  side  of  the  urethra 
completely,  the  elevator  should  be  removed,  and  the  instrument  used 
in  the  same  way  that  Sims's  speculum  is  em- 
ployed in  the  examination  of  the  vagina. 

The  other  instrument  is  a  modification  of 
Folsom's  nasal  speculum,  made  of  wire.  Fig. 
274.  By  turning  the  nut-screw  the  blades  are 
closed,  and  the  instrument  is  introduced ;  and 
by  unscrewing  it  the  elasticity  of  the  handle 
throws  the  blades  apart.  This  instrument  an- 
swers well  when  the  tumor  to  be  removed  is 
small,  and  we  are  obliged  to  operate  without  as- 
sistance. It  is  self-retaining.  The  other  spec- 
ulum is  preferable  in  most  cases,  but,  in  operat- 
ing through  it,  it  is  requisite  that  some  one  should  hold  it. 

When  the  tumor  is  at  or  near  the  meatus,  and  has  a  laree  base. 


Fig.  274.— Skene's  modi- 
fication of  Folsom's 
nasal  speculum. 


904 


DISEASES  OF  WOMEN. 


or  if  it  is  vascular  and  troublesome  haemorrhage  is  feared,  removal 
by  ligature  is  preferable.  Having  exposed  the  part  with  the  specu- 
lum the  base  of  the  tumor  is  to  be  transfixed  by  passing  a  needle 
from  without  inward,  parallel  to  the  axis  of  the  urethra  ;  a  ligature 
is  then  to  be  passed  around  under  the  needle,  then  the  tumor  is 
grasped  with  a  forceps,  and  traction  made  so  as  to  bring  the  sides  of 
the  base  within  the  grasp  of  the  ligature,  which  should  then  be  tied 
slowly  and  as  tightly  as  possible  without  cutting  the  tissues.  By 
taking  all  these  precautions  the  ligature  will  be  certain  to  include 
all  the  abnormal  tissue,  a  very  impoi-tant  result  indeed.  If  the  base 
of  the  growth  is  too  large  to  be  included  easily  in  one  ligature, 
transfixion  may  be  made  with  a  needle  armed  with  a  double  thread, 
and  its  two  halves  tied. 

In  choosing  the  material  for  a  ligature,  I  would  advise  the  use 
of  tine  plaited  silk,  boiled  in  a  mixture  of  beeswax,  carbolic  and 
salicylic  acids.  A  ligature  prepared  in  this  way  ties  easily,  does  not 
stick  like  the  ordinary  ligature,  and,  more  than  that,  it  does  not  slip. 

If  the  tumor  is  within  easy  reach  and  is  pedunculated,  the  pedi- 
cle can  be  seized  with  a  small  forceps,  and  the  tumor  grasped  in  a 
polypus-forceps,  and  removed  by  torsion.  Or  it  can  be  cut  off  with 
the  knife  or  scissors,  and,  if  the  pedicle  inclines  to  bleed,  touched 
with  caustic.  Allen's  polypus-forceps  for  the  ear  will  be  found  one 
of  tlie  most  conven- 
ient instruments  for 
taking  hold  of  these 
little  tumors,  Fig. 
275. 

In  cases  where 
there  are  several 
small  growths  high 
up  in  the  urethra, 
they  can  be  removed 
with  the  curette,  and, 
when  the  haemor- 
rhage has  subsided, 
the  base  of  each 
should  be  cauterized. 

But  little  difficul- 
ty will  be  experienced  in  operating  in  the  various  ways  described 
when  the  neoplasms  are  low  down  in  the  urethra,  where  they  can  be 
easily  seen  and  handled.  When  they  are  high  up  in  the  canal,  then 
great  skill  and  care  are  required  to  remove  them.     In  such  cases 


Fig.  2*75. — Allen's  polypus  forceps. 


ORGANIC  DISEASES   OP   THE   URETHRA.  905 

success  will  be  best  obtained  with  the  ecraseur,  or  the  instrument 
known  as  Blake's  polypus-snare,  used  for  removing  polypi  from  the 
ear,    Fig.   27G.    It  is  simply  a  very  delicate  ecraseur,  the  chain  or 

wire  of  which  is 
C>o  ■'■-■■  '     'i^^  tightened    by  the 

G.TIEMAKN  ^CO.      T^^^  n  .  ,  p 

linger  m  place  ot 
a  screw\  It  will 
be  found  that,  in- 
stead of  the  wire 

T.     ^H.     T,,  ,  ,      1  commonly      used. 

Fig.  276. — Blake's  polypus  snare.  ,  . 

the  steel  -  wire 
Btring  of  the  zither  is  better ;  it  is  stronger,  more  elastic  and  pliable, 
yet  stiff  enough  to  be  manageable.  Dr.  John  W.  S.  Gouley,  of  New 
York,  was  the  first  to  use  this  instrument  for  removing  tumors  of 
the  urethra,  and  I  can  testify  to  its  great  value  in  such  operations. 

In  operating  with  the  snare,  the  tumor  is  exposed  with  the 
urethral  speculum  ;  and,  if  the  growth  is  pedunculated,  the  loop  of 
wire  is  passed  over  it,  and  removal  effected  by  constriction.  When 
there  is  a  broad  base,  the  whole  mass  is  seized  with  the  polypus-for- 
ceps, and  the  snare  is  then  passed  over  it  and  tightened  until  it 
comes  away. 

There  is  one  accident  that  very  often  occurs  in  this  operation, 
and  that  is  breaking  of  the  wire.  This  takes  place,  usually,  just 
when  the  tumor  is  almost  cut  off,  and  it  annoys  and  hinders  the 
operator,  but  does  not  spoil  the  operation,  as  a  new  piece  of  wire 
can  be  used,  and  the  operation  completed.  This  accident  can  often 
be  avoided  by  taking  time.  The  base  or  pedicle  of  most  of  these 
growths  will  give  way  under  long-continued  pressure,  but  the  wire 
will  break  if  there  is  too  much  hurry. 

In  order  to  operate  high  up  in  the  urethra,  it  is  sometimes 
necessary  to  dilate  its  lower  portion.  A  convenient  way  to  do  this 
is  the  following :  Take  a  piece  of  fine  rubber  tubing  and  draw  it 
over  the  blades  of  the  Folsom  speculum,  and  then  introduce  the  in- 
strument into  the  urethra.  Open  the  blades,  and  let  it  distend  the 
urethra  as  far  as  it  can.  To  produce  the  extra  dilatation,  take  a 
series  of  graduated  sounds  or  dilators — wood  or  hard  rubber  will 
answer — and  force  one  of  these  in  between  the  blades  of  the  specu- 
lum ;  remove  that  one,  and  use  a  size  larger,  and  so  on  until  the 
requisite  amount  of  dilatation  is  obtained.  The  blades  of  the  specu- 
lum and  the  rubber  tubing  protect  the  mucous  membrane  of  the 
urethra  from  injury  while  passing  in  the  dilator.  The  danger  of  in- 
continence of  urine,  which  is  Hable  to  follow  from  forcible  dilata- 


906  DISEASES  OF  WOMEN. 

tion,  can  be  avoided  by  distending  the  lower  portion  of  tlie  urethra 
only. 

To  obtain  sufficient  light  for  operating  high  up  in  the  urethra, 
it  is  necessary  to  have  clear  sunlight ;  or,  if  that  is  not  obtainable, 
gaslight  should  be  used ;  and,  in  either  case,  the  concave  head-mir- 
ror should  be  employed. 

Of  late  years  the  galvano-cautery  has  been  very  extensively 
used  in  surgery  generally,  and  has  been  recommended  for  the  re- 
moval of  urethral  tumors.  As  a  means  of  removing  large  and  vas- 
cular growths  from  the  meatus,  it  has  high  claims,  but  for  general 
use  it  will  be  found  objectionable.  In  removing  tumors  from  the  in- 
terior of  the  urethra  with  this  cautery,  it  is  imjDossible  to  avoid  cau- 
terizing portions  of  the  normal  membrane  unless  extraordinary  skill 
is  employed.  This  unfortunate  liability,  and  the  difficulty  in  keep- 
ing the  instrument  in  good  working  order,  stand  in  the  way  of  this 
means  of  operating  ever  becoming  popular  in  this  department  of 
surgery. 

Caustics  have  been  more  extensively  used  than  any  other  means 
of  removing  urethral  neoplasms,  and  I  know  of  no  better  way  of 
destroying  small  growths.  Of  all  the  agents  used,  I  prefer  pm-e 
nitric  acid,  which  I  use  as  follows :  Exposing  the  tumor  with  the 
speculum,  represented  by  Fig.  276,  I  wrap  a  little  cotton  around  a 
probe,  and  dip  it  into  the  acid,  and  apply  it  to  the  j^art  to  be  de- 
stroyed, taking  care  not  to  touch  any  of  the  normal  tissues.  The 
speculum  recommended  has  the  advantage  of  protecting  one  side  of 
the  canal,  and,  by  exercising  care  in  handling  the  acid,  accidents 
may  be  avoided. 

I  come  now  to  the  last  method  of  removing  these  tumors  which 
I  shall  mention,  viz.,  electrolysis.  This  means  of  treating  abnormal 
growths  has  been  employed  so  much  lately  that  I  need  not  dwell 
upon  the  method  of  its  use,  but  simply  state  that  those  tumors  that 
recur,  and  those  that  are  suspected  to  be  malignant,  and  those  also 
that  are  so  high  up  in  the  urethra  as  to  be  difficult  to  remove,  should 
be  treated  by  electrolysis.  Two  long,  slender  needles  should  be  in- 
sulated by  coating  them  with  collodion,  except  at  the  points.  These 
are  attached  to  the  electrodes  of  a  galvanic  battery,  and  their  points 
introduced  into  the  base  of  the  tumor,  and  the  current  passed  through 
until  the  whole  of  the  abnormal  tissue  is  decomposed.  I  prefer  to 
use  a  current  sufficiently  strong  to  char  the  tumor,  and  thereby  com- 
pletely destroy  it. 

There  is  one  rule  which  should  be  kept  in  mind  in  treating 
tumors  of  the  urethra,  and  that  is,  to  be  sure  to  remove  all  the  ab- 


ORGANIC   DISEASES   OF   THE   URETHRA.  907 

normal  tissue.  "Whatever  method  is  employed,  no  portion  of  that 
which  ought  to  be  removed  should  be  left.  I  am  coniident  that 
much  of  the  trouble  experienced  by  the  repeated  return  of  these 
growths  might  be  avoided  by  a  careful  observance  of  this  rule. 

Urethral  catarrh  or  inHammation,  which  frequently  accompanies 
abnormal  growths,  usually  subsides  after  their  removal.  In  some 
cases  it  persists,  and  then  it  should  be  treated  according  to  the 
methods  already  given. 


CHAPTEE  XLIX. 

OEGANIC   DISEASES    OF   THE   URETHRA    (CONTINUED). 
DILATATION,  DISLOCATION,  AND  PROLAPSUS. 

5.  Dilatation  of  the  TJrethra. — Changes  in  the  caliber  of  the  female 
urethra  occur  in  two  forms,  dilatation  and  contraction ;  but  neither 
of  these  is  very  often  met  with  in  practice.  Of  the  two,  dilatation 
is  the  more  common.  The  increase  in  the  size  of  the  urethra  may 
involve  the  whole  canal,  or  be  limited  to  a  portion  of  it.  I  will  first 
speak  of  dilatation  of  the  whole  urethra,  and  then,  dividing  the  canal 
into  thirds,  consider  the  affection  of  each  portion. 

Dilatation  of  the  Whole  Urethra. — It  will  be  understood  that  dila- 
tation to  such  an  extent  as  to  have  the  canal  open  and  its  walls  sepa- 
rated is  an  unknown  condition.  The  true  state  of  things  would  be 
more  correctly  expressed  by  calling  it  an  abnormal  dilatability.  The 
tissues  of  the  walls  of  the  urethra  are  in  such  a  relaxed  condition  as 
to  admit  of  extraordinary  distention  without  injury.  Dilatation  of 
the  whole  urethra  is  not  so  common  as  dilatation  of  a  portion.  Even 
when  the  whole  canal  is  larger  than  it  should  be,  it  will  generally  be 
found  that  it  is  not  uniformly  so.  Some  portions  of  it  are  more 
distended  than  others.  The  extent  to  which  this  dilatation  may 
occur  is  very  great.  A  number  of  cases  are  recorded,  especially  in 
the  German  literature  of  the  subject,  where  copulation  took  place 
for  years  in  the  urethra  instead  of  the  vagina.  In  these  cases  the 
dilatation  was  extreme. 

In  this  affection  the  urethral  walls  and  the  urethro-vaginal  sep- 
tum are  usually  relaxed  and  flabby.  After  a  considerable  time  they 
may  become  indurated  by  infiltration,  or  by  hyperplasia  of  the  con- 
nective tissue.  The  mucous  membrane  is  usually  soft  and  loosely 
adherent  to  the  subjacent  tissues.  Beneath  the  membrane  will  some- 
times be  found  masses  of  enlarged  veins,  which  give  a  dark-bluish 
ap3)earance  to  the  parts.     If  the  meatus  be  distended  like  the  rest  of 

908 


ORGANIC  DISEASES  OP  THE   URETHRA.  009 

tlie  urethra,  the  mucous  membrane,  witli  the  large  veins  beneath  it, 
may  protrude  and  form  tumors,  wliich  will  have  quite  the  appear- 
ance of  rectal  haemorrhoids.  This  is  especially  so  when  the  veins 
are  large  and  numerous,  and  the  mucous  membrane  thin,  so  that 
the  color  of  the  veins  can  be  seen  through  it.  On  the  other  hand, 
if  the  meatus  remains  normal  in  size  nothing  will  be  seen  by  the 
examiner  until  the  catheter  or  sound  is  passed  into  the  urethra, 
when  the  distended  or  distensible  condition  of  the  canal  will  be  de- 
tected. The  dilatation  can  easily  be  made  out,  even  when  the  meatus 
is  normal  in  size,  by  observing  that  the  sound  can  be  moved  about 
in  the  urethra,  conveying  the  same  impression  to  the  hand  as  w^hen 
it  passes  into  the  bladder.  By  making  a  digital  examination  of 
the  vagina  the  enlarged  urethra  can  be  felt,  and  is  usually  elastic 
and  compressible.  Through  Sims's  speculum  the  abnormal  fullness 
or  bulging  of  the  anterior  vaginal  wall  can  be  plainly  seen  and  dis- 
tinguished from  displacement  of  the  urethra.  The  points  of  differ- 
ence between  dilatation  and  displacement  will  be  brought  out  more 
in  detail  further  on. 

When  the  dilatation  has  existed  for  any  length  of  time,  the 
mucous  membrane  is  usually  hypergemic  and  sometimes  catarrhal, 
secreting  a  muco-purulent  material,  which  may  be  seen  escaping  from 
the  meatus,  or  lodged  in  the  folds  of  the  membrane,  where  it  can  be 
observed  through  the  endoscope.  When  the  mucous  membrane  is 
prolapsed  and  forms  a  tumor  outside  of  the  meatus,  it  soon  becomes 
lissured  and  ulcerated,  and  consequently  very  tender  and  painful. 
This  condition  is  produced  by  the  retarded  circulation,  chafing,  and 
the  irritation  from  exposure  to  the  air,  and  the  urine  passing  over  it. 

Dilatation  of  the  Anterior  or  Lower  Third. — This  is  the  rarest  of 
all  the  forms  of  urethral  dilatation,  and  occurs  usually  as  a  conse- 
quence of  some  enlargement  or  swelling  of  the  mucous  membrane, 
neoplasm  of  the  urethra,  or  mechanical  dilatation.  The  dilatation 
may  include  the  meatus  or  it  may  not.  In  rare  cases  it  does  not  at 
first,  but  later  in  the  course  of  the  trouble  the  enlarged  mucous 
membrane  slowly,  sometimes  rapidly,  dilates  the  orifice.  The  gen- 
eral appearances  of  the  parts  are  the  same  as  those  of  which  1  have 
spoken  under  the  head  of  dilatation  of  the  whole  urethra.  When 
the  dilatation  is  due  to  any  abnormal  growth  in  the  urethra,  the 
conditions  presented  will  be  the  same  as  those  already  described 
under  the  head  of  urethral  neoplasms. 

I  have  seen  but  one  case  where  the  lower  end  of  the  urethra 
was  dilated  without  any  recognizable  cause  for  it.  This  was  a  sin- 
gle lady,  thirty-five  years  of  age,  a  school-teacher.     She  had  dis- 


010  DISEASES  OF   WOMEN. 

placement  of  the  uterus  and  catarrh  of  the  cervical  canal,  for  which 
she  consulted  me.  She  had  no  trouble  with  her  urinary  organs. 
While  examining  the  uterus  I  noticed  that  the  meatus  urinarius  was 
peculiarly  formed.  In  place  of  the  concentric  corrugations  of  the 
mucous  membrane  which  form  the  closed  meatus,  the  orifice  was 
funnel-shaped,  and  lay  open  when  the  labia  minora  were  separated. 
About  half  an  inch  of  the  lower  end  of  the  urethra  admitted  a 
Xo.  21  (English)  sound.  The  remainder  of  the  urethra  was  normal, 
and  there  were  no  signs  of  disease  about  the  mucous  membrane  of 
the  dilated  portion.  I  could  obtain  no  history  which  pointed  to  the 
origin  of  the  dilatation,  and  it  caused  no  discomfort  to  the  patient. 

Dilatation  of  the  Posterior  or  Upper  Third. — This  form  of  dilata- 
tion usually  occui-s  in  connection  with  other  pathological  conditions, 
such  as  prolapsus  of  the  bladder  and  urethra.  On  this  account  I 
will  defer  what  is  to  be  said  on  this  subject  until  I  come  to  disloca- 
tions of  the  urethra. 

Dilatation  of  the  Middle  Third  of  the  Urethra. — Dilatation  of  this 
part  of  the  urethra  is  more  common  than  either  of  those  I  have 
described.  I  do  not  desire  to  be  understood  as  saying,  that  it  is  con- 
fined to  exactly  the  middle  third  of  the  urethra,  or  that  the  other 
dilatations  are  confined  to  thirds  only.  It  is  about  a  third,  and  I 
use  the  division  to  fix  the  idea  clearly  in  the  mind  and  for  conven- 
ience of  description. 

In  this  form  of  dilatation  the  anterior  wall  of  the  urethra  main- 
tains its  normal  position,  but  the  central  portion  of  the  canal  being 
distended  settles  down,  so  that  in  time  the  urethra,  in  place  of  be- 
ing a  straight  or  slightly  curved  canal,  becomes  triangular,  the 
upper  wall  being  the  base,  and  the  central  portion  of  the  posterior 
wall  (that  is  midway  between  the  neck  of  the  bladder  and  the 
meatus)  the  apex.  A  cavity  is  thus  formed  in  the  central  portion 
of  the  urethra.  Fig.  277  will  convey  the  idea  of  the  anatomical 
appearances  of  this  affection. 

Tliis  form  of  dilatation  has  been  called  sacculated  urethra  and 
urethrocele.  A  valuable  article  on  this  subject  will  be  found  in  the 
"American  Journal  of  Obstetrics"  for  Fel)ruary,  1871,  by  Nathan 
Bozeman,  M.  D.  Some  of  the  cases  related  there  by  him  are,  in 
my  opinion,  not  simply  urethral  dilatation  alone,  but  dilatation  and 
dislocation  combined.  However,  his  description  of  this  form  of 
trouble  is  the  best  that  I  have  ever  seen,  and  I  prefer  to  give  it  in 
his  own  words.     It  is  as  follows : 

"  In  the  study  of  urethrocele,  the  anatomical  points  to  be  consid- 
ered are  the  triangular  ligament  and  its  relations  with  the  urethra. 


ORGANIC  DISEASES  OP  THE  URETHRA.  911 

the  muscular  structure  of  the  urethra,  and  the  different  relations  of 
the  urethra  to  the  vagina  in  tlie  upper  and  lower  parts  of  its  course. 


Fig.  277. — Dilatation  of  middle  third  of  the  urethra  (urethrocele). 

"  These  anatomical  peculiarities  exert  a  marked  influence  on  the 
etiology  of  the  lesions  in  question,  and  supply  the  first  links  in  the 
long  chain  of  morbid  results  indicated  by  the  histories  of  the  cases 
above  cited,  and  others  known  sometimes  to  follow. 

'^  In  the  male,  stricture,  although  not  the  first  morbid  alteration, 
denotes  the  first  serious  interruption  of  the  stream  of  urine,  and 
superinduces  morbid  changes  in  the  urethra  above  the  prostate 
gland,  in  the  bladder,  the  ureters,  and  the  kidneys. 

"  In  the  female,  rare  as  it  is  to  meet  with  organic  stricture  of  the 
same  kind  as  in  the  male,  the  caliber  of  the  canal  is  quite  as  often, 
if  not  oftener,  compromised,  and  with  due  allowance  for  the  ana- 
tomical differences  of  sex,  the  pathologic  sequences  observe  the 
same  order. 

"  The  starting-point  of  urethral  and  vesical  lesions  in  the  female 
is  to  be  sought  in  the  lower  half  of  the  urethra,  closely  related  in 
front  with  the  triangular  ligament,  and  blending  behind  with  the 
spongy  erectile  tissue  of  the  vagina. 

"  The  caliber  of  the  urethra  may  be  transiently  narrowed  by 


912  DISEASES  OF  WOMEN. 

congestion  of  its  mucous  lining,  or  permanently  narrowed  by  infil- 
tration of  coagiilable  lymph  into  the  underlying  cellulo-elastic  tis- 
sue, which  constitutes  properly  the  so-called  organic  stricture,  as  in 
the  male,  and  which,  however  seldom  met  with,  is  liable  to  the  same 
sequences. 

"  Infiltration  into  the  spongy  erectile  tissue  outside  the  urethra, 
by  plastic  lymph,  is,  I  believe,  by  far  the  most  common  beginning 
of  the  morbid  process,  whatever  be  the  cause  that  produces  it.  This 
interrupts  the  stream  of  urine,  either  by  encroaching  on  the  caliber 
of  the  urethra,  or  by  deflecting  it  beneath  the  triangular  ligament, 
both  cases  being  attended  with  more  or  less  dilatation  above. 

"  The  next  step  in  sequence  is  increased  functional  activity  of  the 
urethral  muscular  coat  in  overcoming  the  obstruction  to  the  flow  of 
urine.  The  result  upon  its  structure  is  hypertrophy,  and  this  will 
be  of  the  eccentric  type,  thickening  the  urethral  walls  while  enlarg- 
ing the  caliber.  Hence  the  ease  with  which  large  catheters  of  a 
proper  curve  pass  at  all  stages  of  the  disease.  False  and  true  hyper- 
trophy here  coexist.  The  true  hypertrophy  increases  j^aW  j9«S5w 
with  the  muscular  contraction,  and  is  followed  by  still  greater  distor- 
tion of  the  canal,  at  an  angle  more  and  more  acute,  as  it  turns  the 
triangular  ligament,  and  with  corresponding  coarctation  of  its  walls 
at  that  point.  This  mechanical  impediment  below  coincides  with 
the  increased  weight  and  volume  of  the  stream  of  urine  above,  to 
put  the  walls  of  the  urethra  on  the  stretch  in  the  upper  part  of  its 
course. 

"  Thus  is  gradually  formed  the  urinous  tumor,  which  drags  down 
in  front  the  adjacent  vaginal  wall,  appearing  as  a  prolapsus  between 
the  nymphse,  and  filling  up  the  ostium  vaginae. 

"  The  looser  attachment  of  the  urethra  to  the  vagina  in  the  upper 
part  of  its  course  facilitates  this  result.  Such  is  the  condition  of  the 
parts  to  which  I  apply  the  term  urethrocele.  Often  confounded 
with  cystocele,  it  is  really  distinct. 

"  The  arrest  and  retention  of  but  a  few  drops  of  urine  at  first 
goes  on  until  this  may  amount  to  a  teaspoonful  or  more.  It  is  then 
decomposed  in  this  pocket,  becomes  alkaline,  and  by  its  irritation 
provokes  congestion  of  the  urethral  mucous  membrane." 

In  the  earlier  stages  of  this  affection  the  urethra  in  front  and 
behind  the  pouch  is  really  or  apparently  contracted ;  but  as  the 
disease  progresses  the  upper  part  of  the  canal  and  the  neck  of  the 
bladder  become  dislocated  downward,  and  finally  the  upper  portion 
of  the  urethra  becomes  also  dilated  to  some  extent. 

There  is  in  this,  as  in  the  other  forms  of  urethral  dilatation,  fre- 


ORGANIC   DISEASES  OF  THE  URETHRA.  913 

qnent  nrination,  usually  more  marked  ;  Vjut  unlike  the  others,  there 
is  difficulty  in  passing  water.  This  frequency  of  urination,  and 
the  straining  efforts  necessary,  affect  the  bladder,  producing  irri- 
tation, and,  in  time,  hypertrophy  of  its  walls.  Cystitis  also  follows 
in  the  order  of  morbid  developments ;  but  whether  that  comes 
from  the  frequent  and  difficult  mination,  or  from  extension  of  the 
inflammation  from  the  urethra  to  the  bladder,  is  a  question.  One 
thing  we  know,  and  that  is,  that  if  this  form  of  uretlu-al  dilatation 
goes  on  without  treatment,  cystitis  will  sooner  or  later  appear. 

Symptomatology . — The  symptoms  vary  according  to  the  extent  of 
the  dilatation,  the  portion  of  the  urethra  involyed,  and  the  condition 
of  the  mucous  membrane.  When  the  whole  urethra  is  dilated,  the 
only  symptom  present  may  be  frequent  urination.  When  there  is 
inflammation  or  prolapsus  of  the  mucous  membrane,  then  pain  will 
be  caused  by  micturition,  and  the  desire  to  micturate  will  be  more 
urgent  and  frequent.  The  patient  may  also  be  annoyed  by  a  slight 
loss  of  control  of  the  bladder,  under  the  pressure  of  lifting  heavy 
weights  or  coughing. 

Dilatatation  of  the  lower  third  of  the  urethra  does  not  cause  any 
derangement  of  function,  unless  accompanied  with  inflammation  or 
idceration ;  then  there  will  be  frequent  urination  possibly,  painful 
urination  certainly.  The  symptoms  in  this  form  of  dilatation  are 
less  marked  than  in  the  other  varieties. 

When  the  trouble  is  located  in  the  upper  third  of  the  urethra, 
the  symptoms  are  sometimes  very  distressing.  In  addition  to  the 
frequent — it  may  be  constant — desire  to  pass  water,  the  patient  is 
tormented  with  partial  incontinence.  Coughing,  laughing,  sneezing, 
stooping  to  lift  anything,  a  jar  on  stepping  from  the  curbstone  in 
crossing  the  street,  causes  an  escape  of  urine.  This  distresses  the 
patient  very  greatly.  She  is  not  troubled  so  long  as  she  keeps  quiet, 
or  at  least  she  suffers  only  from  frequent  urination ;  but  as  soon  as 
she  undertakes  the  usual  duties  of  exercise  or  enjoyment,  then  this 
partial  incontinence  makes  her  miserable.  From  the  constant  wetting 
of  the  external  parts  they  become  inflamed,  unless  very  great  care  is 
taken  to  keep  them  dry  and  clean.  In  some  of  these  cases  the  morti- 
fication is  sometimes  more  distressing  than  the  physical  suffering. 

The  symptoms  occurring  in  dilatation  of  the  middle  portion  of 
the  urethra  (urethrocele)  are  the  same  as  those  already  given,  with 
the  addition  of  a  slight  mechanical  obstruction,  which  causes  difficult 
urination.  That  is,  more  voluntary  effort  is  necessary  on  the  part  of 
the  patient  to  empty  the  bladder.  The  forcing,  straining  efforts 
made  by  some  of  these  patients  wliile  urinating  are  even  greater 
69 


914  DISEASES  OF   WOMEN. 

than  tlie  mechanical  obstruction  appears  to  account  for.  This  maj 
be  due  to  the  accumulation  of  urine  in  the  urethra,  which  excites 
extra  retlex  action  in  the  bladder  and  urethra  out  of  proportion  to 
the  obstruction.  This  is  the  only  way  that  I  can  account  for  the 
difficult  urination  and  muscular  hypertrophy  found  in  these  cases  in 
which  there  is  no  obstruction  from  stricture. 

The  constitutional  symptoms  arising  from  these  urethral  troubles 
are  the  sauie  as  those  produced  by  uretliritis,  and  are  not  peculiar  to 
this  class  of  affections.  In  fact  it  will  be  observed  that  the  symptoms 
here  given  may  all  be  produced  by  other  pathological  conditions,  and 
consequently  can  not  alone  guide  to  correct  diagnoses.  The  clinical 
history  in  such  cases  leads  us  to  suspect  the  nature  of  the  disease, 
but  the  true  character  of  the  trouble  can  only  be  discovered  by 
physical  exploration. 

Diagnosis. — In  dilatation  of  the  whole  urethra,  a  digital  exam- 
ination will  detect  the  increased  space  occupied  by  the  urethra.  The 
canal  encroaches  upon  the  anterior  vaginal  wall,  and  feels  like  a 
ridge  extending  from  the  meatus  to  the  neck  of  the  bladder.  This 
elevation  or  thickening  of  the  urethra  is  elastic  and  compressible  in 
recent  cases  ;  in  those  of  long  standing  where  there  is  hypertrophy, 
the  tissues  are  firm  to  the  touch,  but  still  the  canal  is  compressible. 
The  extent  of  the  dilatation  can  be  measured  by  the  size  of  the 
sound  that  can  be  easily  passed.  If  even  the  ordinary  female  catheter 
is  at  hand  an  idea  of  the  size  of  the  canal  may  be  obtained.  By 
introducing  that  instrument  and  pressing  it  first  against  the  anterior 
wall  and  then  upon  the  posterior,  the  distance  between  the  two  can 
be  approximately  made  out.  While  the  catheter  or  sound  is  in  the 
urethra  the  finger  should  be  introduced  into  the  vagina  and  the 
thickness  of  the  urethral  wall  ascertained.  This  will  give  a  good 
idea  of  the  increase  of  tissue  from  inflammatory  products  or  hyper- 
trophy. 

When  the  meatus  is  dilated  and  the  mucous  membrane  and  en- 
larged vessels  are  prolapsed,  care  must  be  exercised  to  distinguish 
that  condition  from  urethral  neoplasm.  This  can  be  done  by  ob- 
serving that  in  prolapsus  the  opening  is  situated  either  at  the  upper 
side  or  in  the  center  of  the  protruding  mass,  whereas  in  abnormal 
growths  of  the  urethra  the  meatus  surrounds  the  tumor  or  its 
pedicle.  More  than  that,  by  making  pressure  on  the  distended 
vessels  the  size  of  the  prolapsed  membrane  can  be  reduced,  and  the 
membrane  can  be  pushed  up  into  the  canal.  This  can  not  usually 
be  done  with  tumors. 

Dilatation  of  the  lower  third  of  the  urethra  is  easily  diagnosti- 


ORGANIC   DISEASES   OF   TEE   URETHRA.  915 

cated.  A  large  sound  will  pass  in  as  far  as  the  dilatation  extends, 
and  will  be  arrested  when  it  comes  to  that  portion  of  the  canal  which 
has  a  normal  caliber. 

Great  difficulty  will  be  encountered  in  the  diagnosis  of  dilatation 
of  the  upper  third  of  the  urethra,  bat  by  attention  to  the  following 
points  success  will  usually  follow.  By  using  the  sound  it  will  be 
observed  that  while  the  lower  portion  of  the  canal  hugs  the  instru- 
ment firmly,  the  point  of  it  can  be  moved  freely  in  the  upper  part 
of  the  passage.  The  same  impression  is  conveyed  through  the  in- 
strument as  that  which  is  experienced  when  the  sound  enters  the 
bladder ;  only  in  dilatation  of  the  upper  portion  of  the  urethra,  the 
motion  of  the  point  of  the  so  and  is,  of  course,  more  limited.  Again, 
by  introdacing  a  curved  sound,  and  with  it  holding  the  anterior  wall 
of  the  urethra  well  up  under  the  arch  of  the  pubes,  and  then  carrying 
the  finger  of  the  other  hand  along  the  anterior  vaginal  wall,  the 
posterior  wall  of  the  urethra  will  be  found  to  hug  the  sound  until 
the  dilated  portion  is  reached  ;  this  wiU  be  felt  to  lie  away  from  the 
instrument.  By  pushing  up  the  vaginal  and  urethral  walls  at  the 
point  of  dilatation  until  they  touch  the  sound,  and  then  by  remov- 
ing the  pressure  and  allowing  the  parts  to  recede  from  the  sound, 
the  relaxation  can  be  easily  detected. 

In  some  well-marked  cases  of  dilatation  complicated  with  pro- 
lapsus of  the  upper  portion  of  the  urethra,  the  diagnosis  can  be 
clearly  made,  by  slowly  introducing  the  catheter  until  the  urine  be- 
gins to  flow,  and  then  marking  the  catheter  at  the  meatus  urinarius 
and  withdrawing  it.  The  distance  from  the  mark  made  to  the 
upper  edge  of  the  eye  of  the  catheter  indicates  the  length  of  the 
normal  portion  of  the  urethra.  If  that  is  subtracted  from  the 
normal  length  of  the  urethra,  the  remainder  will  indicate  the  length 
of  the  dilated  portion. 

Dilatation  of  the  middle  third  of  the  urethra-^urethrocele — is 
most  likely  to  be  confounded  with  thickening  of  the  urethro-vaginal 
septum.  The  diagnosis  is  made  by  observing  that  the  enlai'gement 
due  to  dilatation  corresponds  to  the  central  portion  of  the  urethra, 
and  that  it  yields  to  pressure  more  or  less.  Also,  by  passing  a 
curved  sound  with  the  point  upward,  the  anterior  wall  of  the  urethra 
will  be  found  to  occupy  its  normal  position.  Withdrawing  the  sound 
and  again  introducing  it  with  the  point  downward  it  will  pass  in- 
ward and  then  down  into  the  pocket  found  at  the  point  of  dilatation, 
where  it  can  be  felt  through  the  vaginal  wall. 

In  all  cases,  except  one,  that  have  come  under  my  observation, 
the  diagnosis  has  been  easily  made  by  this  method  of  examination. 


916  DISEASES  OF  WOMEN. 

The  exception  referred  to  was  a  case  of  periurethral  inflammation, 
in  which  an  abscess  formed  in  the  urethro- vaginal  septum  and  dis- 
charged into  the  urethra.  A  fistulous  opening  from  the  floor  of  the 
urethra  into  the  sac  of  the  abscess  remained.  The  urethra  occupied 
its  normal  position,  and  admitted  the  sound  easily ;  and  by  intro- 
ducing it  with  the  point  downward  it  passed  into  the  sac  of  the 
abscess,  thus  giving  the  physical  signs  of  urethrocele ;  but  the  small 
size  of  the  opening  in  the  floor  of  the  urethra,  the  marked  infiltra- 
tion and  induration  of  the  tissues,  and  the  history  of  the  case,  led 
to  a  diagnosis  of  its  true  character. 

Prognosis. — There  is  no  natural  tendency  to  recovery  in  these 
affections.  If  left  alone  they  generally  get  worse ;  recovery  under 
treatment  is  modified  by  the  location  of  the  dilatation  and  the  dura- 
tion of  the  trouble.  The  conditions  upon  which  an  unfavorable 
prognosis  is  to  be  based  are  bladder  complications,  inflannnation  or 
ulceration  near  the  neck  of  the  bladder,  great  varicosity  of  the  veins, 
and  fatty  degeneration  of  the  muscular  tissue.  In  the  absence  of 
all  these  complications  a  complete  cure  can  be  obtained.  In  all 
cases  great  relief  can  be  secured  by  treatment,  and  the  patient 
guarded  from  getting  worse. 

Causation. — The  hypersemia  of  the  urethra  which  occurs  in 
pregnancy,  and  which  tends  to  produce  overdistention  of  the  veins, 
favors  dilatation  of  the  whole  urethra.  It  is  not  uncommon  to  find 
an  apparent  increase  of  tissue  in  the  walls  of  the  urethra  during 
utero-gestation,  and  the  dilatability  of  the  canal  is  often  increased 
also.  This  condition  of  the  parts  disappears  during  the  involution 
which  takes  place  after  delivery ;  but  when  from  any  cause  the 
process  of  involution  is  interrupted,  the  enlarged  vessels  and  relaxed 
condition  of  the  urethral  walls  remain  and  sometimes  increase. 
When  to  this  state  of  the  parts  a  catarrh  of  the  mucous  membrane 
is  added,  the  enlargement  of  the  membrane  by  swelling  still  further 
increases  the  caliber  of  the  canal. 

The  dilatation  caused  by  passing  calculi  may  remain  permanently, 
and  the  same  may  be  said  of  the  use  of  large  sounds.  Neoplasms 
obstructing  the  meatus,  or  stricture  at  that  point,  may  so  obstruct 
the  escape  of  the  urine  as  to  cause  dilatation  at  all  points  above.  This 
is  no  doubt  one  of  the  most  important  and  frequent  causes  of  dilata- 
tion. Indeed,  the  recognition  of  this  fact  has  led  to  the  suggestion 
of  treating  stricture  of  the  upper  portions  of  the  urethra  by  com- 
pressing the  meatus,  and  then  forcing  the  urine  into  the  urethra  and 
retaining  it  there. 

I  have  already  stated  that  dilatation  of  the  lower  third  of  the  ure- 


ORaANIC   DISEASES   OF  THE   URETHRA.  917 

thra  is  rare,  and  is  usually  due  to  inflammation  of  the  mucous  mem- 
brane at  that  point  or  to  abnormal  growths,  the  distention  remaining 
after  the  causes  that  produced  it  have  been  removed.  This  and 
mechanical  dilatation  from  any  cause  cover  the  etiology  of  this  form 
of  the  dilatation.  Baker  Brown  says  that  the  meatus  is  always 
dilated  when  there  is  stone  in  the  bladder. 

Regarding  dilatation  of  the  upper  third  of  the  urethra,  I  am  in- 
clined to  believe  that  it  occurs  in  consequence  of  a  partial  prolapsus 
of  the  bladder  and  the  upper  end  of  the  urethra.  The  displacement 
of  these  parts  implies  a  relaxation  of  the  tissues,  caused  originally, 
it  may  be,  by  injuries  during  confinement,  and  the  prolapsus  permits 
an  unusual  pressure  of  the  urine  upon  the  upper  end  of  the  urethra, 
and  dilatation  is  the  result.  On  the  other  hand,  the  prolapsus  and 
the  accompanying  relaxation  of  the  urethral  walls  may  be  sufficient 
to  cause  the  dilatation,  and  the  whole  trouble  can  invariably  be  traced 
to  child-bearing  or  anteversion  of  the  uterus.  The  fact  that  the 
upper  part  of  the  urethra  is  torn  from  its  attachment  to  the  subpubic 
ligament,  and  thereby  deprived  of  its  normal  supports,  would  incline 
it  to  dilate,  and  I  presume  that  this  is  oftentimes  the  cause  of  the 
dilatation. 

One  cause  of  dilatation  of  the  middle  third  of  the  urethra  (ure- 
throcele) has  been  sufficiently  dwelt  upon  in  Bozeman's  description 
of  the  pathology  of  that  affection — that  is,  narrowing  of  the  lower 
end  of  the  urethra.  This  does  not  explain  the  etiology  of  all  cases, 
however,  for  I  have  seen  this  form  of  dilatation  where  there  was  no 
stricture  or  hypertrophy  of  the  lower  end  of  the  urethra.  In  such 
cases  I  have  traced  the  cause  to  childbirth,  during  which  the  pos- 
terior wall  of  the  urethra  had  been  pushed  downward  and  contused, 
while  the  upper  remained  in  its  normal  position.  The  relaxation 
caused  by  this  overstretching  of  the  urethral  wall  formed  a  small 
pocket  in  the  central  portion,  which  gradually  dilated  more  and  more 
by  the  pressure  of  the  urine  until  the  urethrocele  w^as  fully  devel- 
oped. This  explanation  of  the  cause  may  be  rather  hypothetical, 
but,  so  far  as  my  observations  go,  it  agrees  with  the  facts  found  in 
those  cases  which  can  not  be  accounted  for  by  Bozeman's  views  on 
the  pathology  of  this  affection. 

Treatment. — In  the  management  of  all  forms  of  urethral  dila- 
tation, any  inflammation  of  the  mucous  membrane  that  may  exist 
should  be  relieved  by  employing  the  usual  methods  of  treatment  of 
urethritis.  When  there  is  a  relaxed  and  prolapsed  condition  of  the 
mucous  membrane,  astringents  should-  be  used  to  overcome  it.  Tan- 
nic acid  will  answer  well.     When  these  fail,  the  redundant  mem- 


918  DISEASES  OP  WOMEN. 

brane  should  be  retrenched,  either  by  touching  it  with  the  thermo- 
cautery or  excising  a  portion  with  the  scissors.  In  employing  the 
cautery  for  this  purpose,  the  long-pointed  tip  of  the  instrument 
which  is  used  for  cauterizing  haemorrhoids  by  puncture  should  be 
chosen,  and,  having  protected  one  side  of  the  uretlira  with  the  specu- 
lum, a  narrow  strip  of  the  membrane  parallel  to  the  axis  of  the 
canal  shall  be  cauterized.  Two  or  more  of  these  cauterizations  may 
be  made  at  points  equidistant  on  the  circumference  of  the  urethra. 
Operating  in  this  way  leaves  pieces  of  normal  membrane  between 
the  portions  cauterized,  which  prevents  stricture  from  occurring 
after  healing — a  misfortune  which  is  sure  to  follow  if  the  mucous 
membrane  is  destroyed  by  cauterization  all  round. 

In  excising  the  prolapsed  portion,  I  prefer  to  remove  one  or  more 
Y-shaped  portions  on  opposite  sides,  and  bring  the  edges  together 
by  sutures.  This  is  preferable  to  clipping  off  the  whole  of  the  pro- 
truding mass,  because  the  cicatrices  left  are  less  likely  to  give  after- 
trouble  by  contraction. 

When  the  dilatation  is  caused  by  varicose  veins,  it  may  be  well 
to  follow  the  example  of  Gustavo  Simon.  He  exposed  the  vessels 
by  cutting  through  the  vaginal  wall,  ligated  the  largest,  and  arrested 
the  haemorrhage  from  the  smaller  ones  by  applying  liquor  ferri  per- 
chloridi.  He  repeated  this  operation  several  times  on  the  same  pa- 
tient, who  experienced  little  or  no  inconvenience  from  the  proceed- 
ings, and  made  a  good  recovery. 

Dilatation  of  the  lower  third  of  the  urethra  is  usually  secondary 
to  some  other  trouble,  as  I  have  already  stated,  and  all  that  the  physi- 
cian will  usually  be  called  upon  to  do  for  such  cases  is  to  remove  the 
cause  and  treat  any  inflammation  that  may  exist.  The  dilatation  will 
then  disappear,  and,  if  it  does  not,  but  little,  if  any,  trouble  will  I'esult. 

The  treatment  of  dilatation  of  the  upper  third  consists  simply  in 
supporting  the  parts.  This  can  be  effectually  done  by  using  the 
pessary  already  recommended  for  the  relief  of  prolapsus  of  the  blad- 
der. It  will  be  necessary  to  have  the  instrument  so  formed  as  to 
bring  the  pressure  where  it  is  required.  This  can  easily  be  done  by 
placing  the  pessary  in  position,  and  observing  what  change  of  form, 
if  any,  is  necessary,  and  then  directing  the  instrument-maker  to  make 
the  alteration.  If  the  parts  are  well  supported  in  this  way,  recovery 
will  follow,  unless  atrophy  of  the  muscular  wall  has  previously  taken 
place.  Even  then  the  patient  can  be  kept  comfortable  by  wearing 
the  pessary.  If  there  is  urethritis  present,  it  may  be  necessary  to 
relieve  that  before  using  the  pessary ;  otherwise,  the  pressure  of  the 
instrument  maj-  cause  pain,  and  aggravate  the  inflammation. 


ORGANIC   DISEASES   OF   THE   URETHRA.  919 

This  brings  me  to  the  only  remaining  form  of  this  affection  to  be 
mentioned — dilatation  of  the  middle  third,  or  urethrocele.  Dr.  Boze- 
man  has  proposed  making  an  opening  into  the  most  dependent  part 
of  the  urethra  through  the  vaginal  wall,  and  maintaining  it  until  all 
inliammation  has  been  relieved,  and  then  closing  the  opening  by  the 
usual  plastic  operation.  By  this  means  the  urethra  is  perfectly 
drained  of  urine  and  the  products  of  inflammation  which  accumu- 
lated thei-e  before.  This,  with  appropriate  cleansing  and  topical 
applications,  soon  restores  the  mucous  membrane  to  its  normal  con- 
dition, and  the  removal  of  the  redundant  tissue  during  the  operation 
of  closing  the  opening  effectually  cures  the  whole  trouble.  This 
treatment  is  admirably  adapted  to  marked  cases  of  long  standing, 
and  should  be  employed.  By  using  the  thermo-cautery  to  make  the 
opening,  the  operation  is  easily  performed.  In  recent  cases  of  less 
■severity,  I  have  obtained  satisfactory  results  by  dilating  the  lower 
part  of  the  urethra,  and  supporting  the  dilated  portion  either  with  a 
pessary  or  a  tampon  of  marine  lint.  This  permits  the  urethra  to 
keep  itself  empty,  and  then,  by  frequently  washing  it  out  and  apply- 
ing such  remedies  as  will  cure  the  urethritis,  recovery  will  sometimes 
follow.  This  treatment  can  be  tried,  and,  if  it  fails,  Bozeman's 
method  can  be  resorted  to.  Dr.  T.  A.  Emmet  has  extended  the 
usefulness  of  this  operation.  He  calls  it  button-holing  the  urethra, 
and  employs  the  operation  for  diagnostic  purposes  as  well  as  for  the 
■cure  of  various  affections  of  the  urethra  and  bladder.  I  have  tried 
this  operation  as  faithfully  as  I  could,  and  find  that  it  is  easily  per- 
formed by  using  a  scissors  modified,  but  like  the  button -hole  scissors 
used  by  tailors  (Fig.  2Y8). 


Fig.  278. — Button-hole  scissors  (Skene). 


The  probe-jpointed  blade  is  introduced  into  the  urethra,  and  the 
short  blade  into  the  vagina  as  far  as  the  point  at  which  the  opening 
is  to  be  made.  One  clip  usually  is  sufficient,  but  if  a  larger  opening 
be  desired,  it  can  be  made  by  carrying  the  scissors  up  or  down,  and 
dividing  as  much  more  of  the  septum  as  may  be  desired. 

This  operation  is  most  thoroughly  efficient  for  the  purpose  desig- 
nated for  it  by  Dr.  Bozeman,  and  it  is  also  a  convenient  way  of  re- 
moving neoplasms  situated  in  the  middle  and  upper  thirds  of  the 


920 


DISEASES  OF  WOMEN. 


urethra,  when  they  can  not  be  easily  reached  through  the  meatus 
urinarius.  In  regard  to  this  operation,  as  a  means  of  diagnosis,  I 
have  not  been  able  to  discover  that  it  has  any  advantages,  either  to 
the  patient  or  surgeon,  over  the  methods  I  have  already  described. 
On  the  contrary,  so  far  as  simplicity,  safety,  facility,  and  efficiency 
are  concerned,  it  is  very  inferior. 

6.  Dislocations  of  the  Urethra. — This  is  one  of  the  affections  that 
will  frequently  be  met  with  in  practice,  although  very  little  is  said 
about  it  in  text-books.  I  have  found  very  few  cases  recorded  in 
medical  literatm-e.  This  neglect  of  the  subject  by  authors  is  perhaps 
due  to  the  fact  that  in  many  cases  of  displacement  of  the  urethra, 
the  bladder  is  also  dislocated,  and  the  whole  trouble  is  described 
under  the  head  of  vesicocele  or  cystocele.  Now  it  is  true  that  dis- 
placement of  the  two  occurs  together,  but  it  will  also  be  found  that 
either  may  take  place  alone.  It  is  not  by  any  means  uncommon  to 
find  prolapsus  of  the  bladder  while  the  urethra  is  in  its  normal  posi- 
tion, and  occasionally  a  case  will  occur  in  which  the  urethra  is  pro- 
lapsed, while  thebladder  remains  in  its  proper  place. 

The  urethra  is  subject  to  displacement  upward  and  downward. 
In  pelvic  tumors  the  bladder  is  sometimes  pushed  up  out  of  the  pel- 
vic cavity,  and  the  urethra  dragged  along  with  it.  Usually  no  harm 
comes  from  this  displacement,  except  that  it  may  cause  some  difficulty 
in  using  the  catheter,  should  this  be  necessary ;  hence  I  need  not 
dwell  on  this  part  of  the 
subject.  Dislocations 
downward  are  the  most 
important  because  they 
occur  more  frequently, 
and  almost  invariably 
cause  suffering  to  those 
so  affected. 

The  extent  of  dis- 
placement varies  ex- 
ceedingly, but  I  shall 
describe  only  the  par- 
tial and  the  complete. 
A  clear  comprehension 
of  these  two  degrees 
will  cover  all  interme- 
diate forms.  In  partial 
displacement  downward,  the  upper  two  thirds  of  the  urethra  are  pro- 
lapsed, so  that  the  direction  of  that  portion  of  the  canal  is  backward, 


Fig. 


279. — Dislocation  of  the  upper  third  of  the  urethra. 
s,  symphysis  pubis  ;  r,  rectum. 


ORGANIC  DISEASES  OF  THE   URETHRA. 


921 


instead  of  curving  upward,  as  in  the  normal  condition.     Fig.  279 
will  convey  the  idea  of  this  degree  of  dislocation. 

In  complete  prolapsus  the  urethra  runs  from  the  meatus  (which 
is  in  its  normal  position)  backward,  and  rests  upon  the  perinneum ;  or 
in  extreme  cases,  accompanied  with  prolapsus  of  the  bhidder  and 
uterus,  its  direction  is  backward  and  downward  ;  the  position  of  the 
vesical  end  of  the  urethra  being  below  the  level  of  the  meatus.  In 
this  degree  of  displacement  the  urethra  and  bladder  can  be  seen  pre- 
senting at  the  vulva,  or  lying  between  the  labia  minora  or  thighs. 


Fig.  280. — Complete  dislocation  of  the  urethra  with  dilatation,     c,  urethra. 

The  urethra  is  usually  shortened  considerably  when  the  prolapsus  is. 
marked.     Fig.  280  illustrates  complete  dislocation. 

Symptomatology . — The  symptoms  arising  from  displacement  of 
the  urethra  are  much  the  same  as  those  found  in  dilatation  and 
other  urethral  diseases.  I  need  not,  therefore,  repeat  them  in  detail. 
Suffice  it  to  say,  that  in  dislocation  of  the  upper  portion  of  the  canal, 
there  is,  in  addition  to  frequent  urination,  a  partial  loss  of  control  of 
the  bladder.  Under  the  extra  pressure  of  coughing,  for  example, 
the  urine  will  escape.  This  loss  of  control  does  not  exist,  as  a  rule, 
in  complete  displacement.  On  the  contrary,  there  is  usually  diffi- 
cult urination,  which  requires  increased  voluntary  efforts  to  empty 
the  bladder.     In  some  cases  the  bladder  can  not  be  emptied  until 


922  DISEASES  OP  WOMEN. 

it  is  pushed  up  into  position.  In  all  degrees  of  displacement,  the 
symptoms  are  increased  in  the  erect  position,  and  are  markedly  re- 
lieved when  the  patient  lies  down. 

Diagnosis. — An  examination  of  the  vagina,  either  by  the  touch 
or  speculum,  will  reveal  the  downward  projection  of  part  or  all  of 
the  urethra,  which  will  demonstrate  that  there  is  either  dilatation  or 
prolapsus.  The  two  conditions  can  then  be  differentiated  by  the  use 
of  the  sound.  The  change  in  the  direction  of  the  canal  will  be 
shown  as  the  sound  passes  in,  and  dilatation  can  be  excluded  by  ob- 
serving that  the  urethra  grasps  the  instrument  firmly  at  all  points. 
In  dislocation  of  the  upper  two  thirds  of  the  urethra,  it  will  be  found 
that  the  sound  passes  in  the  normal  direction,  but  is  arrested  at  half 
or  three  quarters  of  an  inch  from  the  meatus ;  but,  by  pushing  up 
the  vaginal  wall  and  the  urethra,  the  sound  will  then  pass  into  the 
bladder.  When  the  prolapsus  is  complete,  the  instrument  passes  in 
easily,  but  takes  a  downward  and  backward  direction. 

Prognosis. — Uncomplicated  displacement  of  the  urethra  can  be 
remedied  in  the  great  majority  of  cases,  if  the  trouble  has  not  been 
of  long  standing.  By  placing  the  parts  in  proper  position,  and  hold- 
ing them  there,  the  relaxed  tissues  will  usually  contract  sufficiently 
to  support  themselves.  Should  they  fail  to  do  so,  the  patient  can  be 
at  least  made  comfortable  by  wearing  some  supporter.  In  many 
cases  the  pelvic  floor  is  imperfect,  and  by  restoring  it  and  bringing 
the  parts  together  high  up  the  urethra  will  be  kept  in  place  by  the 
natural  supports. 

Causation. — Utero-gestation  and  delivery  are  the  most  important 
causes  of  this  affection.  In  the  advanced  months  of  pregnancy  I 
have  observed  that,  while  the  bladder  rose  above  the  pubes,  the 
urethra  was  pushed  slightly  downward  by  the  settling  of  the  en- 
larged uterus  into  the  pelvis.  In  such  cases,  when  labor  occurs,  the 
head  of  the  child  dislocates  the  urethra  still  more,  by  pushing  it 
still  farther  down.  This  process  1  have  often  w\atched  in  forceps 
delivery.  When  the  child's  head  is  large,  and  there  is  a  partial  pro- 
lapsus of  the  urethra  existing  before  the  forceps  are  applied,  one  can 
see  during  traction  that  the  urethra  and  anterior  vaginal  wall  are 
forced  down  before  the  advancing  head,  and  that,  too,  while  counter- 
pressure  to  prevent  it  is  being  made.  The  displacement  produced 
in  this  way  is  often  corrected  during  convalescence,  if  proper  care  be 
taken  to  push  the  parts  back  into  place,  and  the  patient  kept  at  rest 
until  the  tissues  regain  their  tonicity.  But  in  many  cases  the  trouble 
is  overlooked,  and,  by  permitting  the  patient  to  get  up  and  be  on 
her  feet  while  there  is  still  prolapsus,  it  will  slowly  increase,  until 


ORGANIC   DISEASES   OF   THE  URETHRA.  923 

the  dislocation  is  complete.  This  will  surely  be  the  case  if  there  is 
any  loss  of  perinseum.  Indeed,  rupture  of  the  perinseuni  is  an  acci- 
dent which  permits  the  urethra  to  descend  from  its  place.  I  believe 
that  the  pei'inseum  supports  the  vaginal  walls,  which  in  turn  support 
the  urethra ;  and  if  the  pennseum  is  lost,  even  in  part,  the  vaginal 
walls  become  relaxed,  or  perhaps  never  regain  their  tonicity  after 
delivery,  and,  settling  down  more  and  more,  carry  the  urethra  with 
them.  I  need  hardly  repeat  what  has  ah'eady  been  said,  that  dis- 
placements of  the  uterus  often  cause  malposition  of  the  bladder  and 
urethra. 

Treatmnent. — When  the  displacement  of  the  urethra  is  caused  by 
any  other  affection,  such  as  defective  perinseum  or  prolapsus  uteri, 
then  these  things  should  first  be  attended  to.  Should  there  be 
urethritis,  that  also  should  receive  approj^riate  treatment.  But  the 
chief  indication  is  to  retain  the  urethra  in  place,  and  this  may  be 
accomplished  by  using  the  pessary  which  has  been  recommended  for 
supporting  the  prolapsed  bladder.  Prolapsus  of  the  upper  part  of 
the  urethra  can  be  remedied  in  this  way  quite  satisfactorily.  When 
the  whole  urethra  is  displaced  this  instrument,  while  it  supj^orts  the 
upper  part,  will  still  permit  the  middle  portion  of  the  urethra  to 
settle  down.  This  may  be  remedied  by  making  the  anterior  portion 
of  the  pessary  long  enough  to  engage  in  the  introitus  vulvae,  and  in 
that  way  keep  the  whole  canal  where  it  should  be.  Should  this 
cause  the  patient  much  discomfort  the  vagina  may  be  tamponed 
with  marine  lint,  and  the  parts  kept  in  position  until  the  trouble  is 
partially  overcome,  and  then  the  pessary  will  complete  the  treatment, 

ILLUSTRATIVE    CASE. 

By  way  of  illustrating  what  has  been  said  on  this  subject,  I  will 
give  the  history  of  a  case  which  may  be  accepted  as  a  fair  repre- 
sentative of  such  as  will  oftentimes  be  met  in  practice. 

A  lady,  fifty-seven  years  of  age,  who  had  borne  seven  childi'en, 
and  possessed  excellent  general  health,  was  very  much  troubled  by  a 
partial  loss  of  control  over  the  bladder.  While  at  rest  she  had  no 
difiiculty,  but  on  coughing,  laughing,  stooping,  or  lifting  any  heavy 
weight,  the  urine  would  escape  in  spite  of  her  efforts  to  control  it. 
I  found  the  upper  two  thirds  of  the  urethra  displaced  downward. 
Upon  separating  the  labia,  the  urethra  and  vaginal  wall  presented 
just  within  the  introitus,  like  the  tumor  seen  in  prolapsus  of  the 
anterior  vaginal  wall  or  cystocele.  Introducing  the  catheter,  I  ob- 
served that  it  passed  in  the  usual  direction  for  about  three  eighths 
or  half  an  inch,  and  then  turned  downward  and  backward,  in  the 


924  DISEASES  OF  WOMEN. 

direction  of  the  hollow  of  the  sacrum.  I  also  satisfied  myself  that 
the  urethra  was  not  dilated,  by  observing  that  it  grasped  the  catheter 
firmly  throughout  its  whole  extent.  It  was  shortened  to  about  an 
inch.  This  I  ascertained  by  slowly  passing  the  catheter  until  the 
urine  began  to  flow,  and  then  withdrawing  the  instrument  and 
measuring  from  its  eye  to  the  point  marked  at  the  meatus  urinarius. 

A  pessary  was  fitted  to  keep  the  parts  in  place,  and  very  marked 
relief  was  at  once  secured. 

From  the  nature  of  the  dislocation,  and  the  very  prompt  relief 
following  the  treatment,  I  am  inclined  to  think  that  the  incontinence 
in  cases  such  as  this  is  due  to  the  settling  down  of  the  upper  por- 
tion of  the  urethra,  by  which  the  pressure  of  the  bladder  and  its  con- 
tents falls  directly  on  the  sphincter  vesicae,  and  overcomes  its  resist- 
ing power.  Whether  this  is  the  correct  explanation  or  not,  one 
thing  is  certain,  and  that  is,  that  cases  like  the  foregoing  are  often 
met  in  practice,  and  the  treatment  of  restoring  the  dislocated  urethra 
gives  prompt  relief. 

It  must  not  be  supposed  from  what  has  been  said  about  this  case, 
that  the  partial  loss  of  retentive  power  in  the  bladder  so  frequently 
met  with  in  women  who  have  borne  children,  is  always  due  to  dis- 
location of  the  urethra.  The  following  case  will  illustrate  sufliciently 
well  a  class  whose  symptoms  might  lead  to  the  suspicion  of  disloca- 
tion of  the  urethra  when  it  did  not  exist : 

A  lady,  fifty-five  years  of  age,  the  mother  of  six  children,  con- 
sulted me  on  the  subject  of  her  urinary  troubles.  She  said  that  she 
was  obliged  to  urinate  oftener  than  she  used  to,  and  that  she  could 
not  stand  or  walk  for  any  length  of  time  without  being  annoyed  by 
the  dribbling  of  urine. 

She  was  rather  out  of  health.  Her  digestion  was  labored,  and 
she  was  antemic  and  easily  fatigued.  Dislocation  of  the  urethra 
was  suspected,  but  upon  examination  the  pelvic  organs  were  all 
in  proper  position  and  free  from  disease,  except  that  there  was  a 
want  of  muscular  tonicity  of  the  perinoeum  and  vagina.  The  ure- 
thra was  congested  throughout  its  entire  extent,  and  supersensitive, 
especially  at  its  upper  portion.  There  was  also  some  slight  dilata- 
tion, or  aVjnormal  dilatability,  of  the  upper  two  thirds  of  the  canal. 

She  was  treated  with  vaginal  injections  of  cold  water,  applica- 
tions of  tannin  in  solution  to  the  urethra,  and  tonics,  including  small 
doses  of  nux  vomica.  As  her  general  health  improved,  the  urinary 
troubles  gradually  left  her.  This  case  properly  belongs  to  the  class 
of  dilatations,  but  is  given  here  to  show  its  resemblance  to  that  of  dib- 
locations. 


^ 


FIG.282 
PAGE946. 


R    L.D.  DtL. 


tin 


PLATE   IV. 

Figure  382.     Page  946. 

Inflammation  of  the  Urethkal  Glands. 

The  hyperplasia  of  the  mucous  membrane  about  the  mouth 
of  the  ducts  is  usually  called  caruncle. 

The  red  points  about  the  vulva  show  inflammation  caused 
by  the  discharge  from  the  glands. 

'•■  Figure  381.     Page  935. 

.Operation  for  Prolapsi's  of  the  Bladder  and  Urethra. 

..  Incision  on  the  lower  side,  and  buried  suture  partly  intro- 
,  duced.  The  line  on  the  upper  side  shows  the  location  of  the 
<  incision. 

V ,. 
canal,     "i 

!  r   >  U . .     . . 


:s  partially  et; 

The  longei  i 
♦I'^'comes,  and  thi 


>.n>iA 


boaiiBO  aoii&amiBhai  nrocUj  -■^■tnioq  bs-r  orlT 


'orirrK  ! 
sdi  ')nil  9£n 


ORGAXIC  DISEASES  OF   THE   URETHRA.  925 

The  failure  (in  certain  cases)  of  all  methods  of  treatment  led  me 
to  devise  the  following  operation  for  the  relief  of  prolapsus  of  the 
urethra.  An  incision  is  made  on  each  side  of  the  m-ethra  down 
through  the  vaginal  wall,  and  extending  from  half  an  inch  within 
the  vulva  upward  and  outward  an  inch  or  more.  The  edges  of  the 
wounds  are  retracted,  and  with  a  buried  catgut  suture  the  tissues 
below  the  vaginal  wall  are  drawn  together  and  at  the  same  time 
united  to  the  fascia  which  forms  the  subpubic  ligament.  Another 
row  of  sutures  unites  the  deeper  portion  of  the  vaginal  wall,  and 
the  third  closes  the  surface  portion  of  the  wound. 

No  tissue  at  all  is  removed.  The  object  of  the  operation  is  to 
gather  together  the  tissues  on  each  side  of  the  urethra,  and  unite 
them  to  the  fascia  above.     See  Fig.  281,  Plate  IV. 

I  am  unable  to  speak  from  sufficient  experience  regarding  the 
results  of  this  operation,  but  it  promises  to  be  of  great  value. 

Prolapsus  or  Inversion  of  the  Urethral  Mucous  Membrane, — This 
subject  has  been  already  spoken  of  in  connection  with  ui-ethral 
dilatations,  and  little  more  need  be  said  about  it,  except  to  mention 
that  it  occasionally  occurs  as  a  distinct  affection.  In  fact  the  mem- 
brane can  not  become  inverted  unless  there  is  a  change  in  its  stract- 
ure  and  its  relations  to  the  tissues  beneath  it.  Hence  it  must  in  all 
cases  be  a  secondary  affection.  The  membrane  must  be  increased  in 
extent  of  surface,  either  from  relaxation  of  its  fibers  or  hyperplasia, 
and  its  basic  attachments  be  loosened,  before  it  can  be  prolajDsed. 
These  changes  are  doubtless  the  result  of  malnutrition  in  the  fonn 
of  degeneration. 

The  prolapse  may  be  limited  to  one  side,  or  extend  all  around  the 
canal.  The  size  and  extent  of  the  protrusion  varies  considerably. 
If  the  meatus  is  of  full  size,  the  prolapsed  portion  will  usually  pre- 
serve its  natural  color  for  a  time  ;  but  after  a  while,  from  chafing 
when  wet  with  urine,  and  especially  if  not  kept  clean,  it  will  become 
red  and  oedematous.  When  the  meatus  is  small,  these  changes  occur 
sooner  and  in  a  more  marked  degree,  because  the  prolapsed  portion 
is  partially  strangulated. 

The  longer  the  membrane  remains  exposed,  the  more  sensitive  it 
becomes,  and  the  frequency  of  urination  and  pain  attending  it  in- 
creases. It  also  becomes  very  tender  and  painful  to  the  touch.  In 
marked  cases  the  ordinary  movements  of  the  body  irritate  the  parts, 
and  in  that  way  render  walking  painful. 

These  are  symptoms  that  closely  resemble  those  of  irritable 
growths  at  the  meatus  urinarius  ;  and,  so  far  as  history  is  concerned, 
it  will  not  be  possible  to  make  a  differential  diagnosis.     To  do  this  it 


926  DISEASES   OF   WOMEN. 

is  necessary  to  make  a  local  examination.  The  physical  signs,  and 
the  points  in  the  diagnosis  between  this  affection  and  other  diseases, 
have  been  given  briefly  but  sufficiently,  under  the  head  of  dilatations 
of  the  uretlira,  and  need  not  be  repeated  here. 

Pi'ognosis. — This  disease  does  not  yield  promptly  to  mild  treat- 
ment, unless  it  is  seen  early  in  its  progress;  and  if  it  does  yield  to 
mild,  soothing,  and  astringent  applications,  it  is  liable  to  return. 
But  in  case  there  is  no  other  disease  present  that  tends  to  keep  it 
up,  it  can  usually  be  cured  by  surgical  means. 

Causation. — The  causes  of  prolapsus  of  the  urethral  mucous 
membrane  are  numerous,  but  those  that  are  best  known  are  long 
continued  congestion,  urethral  and  cystic  irritation,  causing  frequent 
urination,  and  vesical  tenesmus.  Chlorotic  and  greatly  debilitated 
women  are  said  to  be  predisposed  to  it,  as  also  old  prostitutes.  The 
few  cases  that  I  have  seen  were  in  women  over  hfty  years  of  age, 
and  all  of  them  were  weak,  nervous  patients,  who  had  suffered  from 
some  organic  disease  or  functional  derangement  of  the  urinary 
organs. 

When  a  case  is  first  seen  it  is  well  to  remove  any  inflammation  or 
other  complicating  conditions.  The  prolapsed  membrane  should  be 
replaced,  and  the  patient  kej)t  quiet  in  bed,  to  favor  the  retention  of 
the  parts  in  situ.  Astringents,  such  as  tannic  acid,  alum,  or  persul- 
phate of  iron,  in  a  mild  solution,  should  also  be  used.  Should  these 
fail,  resort  must  then  be  had  to  the  operation  for  removal  of  the  pro- 
lapsed portion  of  the  membrane.  The  methods  of  doing  this  (by 
excision  and  the  thermo-cautery)  have  already  been  described. 

It  only  remains  for  me  to  say  that  Winckel  operates  by  clipping 
off  the  prolapsed  |)ortion  of  the  membrane,  and  then  stitching  the 
internal  edge  of  the  membrane  to  the  edge  of  the  meatus  with  silver 
wire,  allowing  the  sutures  to  remain  in  place  for  from  five  to  seven 
days.  If  the  operation  is  performed  in  this  way  the  patient  must  be 
kept  under  observation,  to  see  if  contraction  of  the  meatus  takes 
place  ;  and  if  it  does,  it  should  be  treated  by  dilatation. 


CHAPTEE  L. 

OEGANIC   DISEASES    OF    THE   TJKETHEA    (cONTmUED). 

STRICTURE,    FOREIGN   BODIES,   AND    INCOMPLETE    FISTULA, 

8.  Stricture  of  the  Tlrethra. — Obstruction  of  tlie  urethra,  by  nar- 
rowing of  its  caliber,  is  a  mucli  less  common  affection  in  the  female 
than  in  the  male  ;  still  it  occurs  sufficiently  often  to  demand  atten- 
tion. There  are  some  facts  in  the  pathology  of  urethral  stricture, 
peculiar  to  women,  which  I  will  first  notice.  Passing  over  congeni- 
tal narrowing  of  the  urethra,  by  simply  saying  that  such  a  malfor- 
mation has  been  seen,  we  find  that  stricture  is  developed  in  the 
female,  as  in  the  male,  by  the  deposit  of  inflammatory  products 
beneath  the  mucous  membrane,  which  by  gradual  contraction  con- 
strict the  canal.  Ulceration  of  the  membrane  in  a  marked  degree 
produces  the  same  results.  The  inflammation  and  ulceration  which 
end  in  the  formation  of  stricture  are  usually  specific  in  character ; 
but  the  same  may  follow  from  the  too  free  use  of  caustics,  and  in- 
juries during  childbirth.  Stricture  may  also  be  produced  by  bands 
of  scar  tissue  formed  in  the  anterior  vaginal  wall  and  stretching  across 
the  urethra.  Contraction  of  the  whole  canal  occasionally  occurs  in 
cases  of  vesico-vaginal  fistula  of  long  standing.  There  the  narrowing 
is  simply  the  result  of  disuse.  The  form  of  stricture  that  will  most 
frequently  come  under  observation  will  be  a  contraction  of  the 
meatus  urinarius,  produced  in  many  cases  by  the  too  liberal  use  of 
caustics  in  the  treatment  of  abnormal  growths  at  the  lower  end  of 
the  urethra,  or  from  vulvitis.  This  form  of  stricture  is  the  least 
troublesome,  and  is  easily  relieved.  When  due  to  the  results  of 
former  urethritis  or  peri-urethritis,  the  walls  of  the  urethra  are 
thickened  and  indurated  at  the  point  of  the  stricture,  and  there  is 
usually  subacute  urethritis,  sometimes  ulceration.  In  those  cases 
where  the  cahber  of  the  canal  is  diminished  by  cicatrices  of  the 
vaginal  walls,  and  in  general  contraction  of  the  urethra  in  vesico- 

927 


928  DISEASES  OF  WOMEN. 

vaginal  fistula  of  long  standing,  the  mucous  membrane  may  be  per- 
fectly normal. 

Syinptomatology . — Frequent  and  difficult  urination  are  the  chief 
troubles  caused  by  stricture  of  the  urethra.  The  stream  becomes 
smaller,  and  may  be  twisted  or  flat,  but  this  is  rarely  observed. 
Patients,  as  a  rule,  only  notice  that  they  require  to  urinate  more  fre- 
quently and  that  they  have  to  make  more  voluntary  efforts  to 
empty  the  bladder  than  were  necessary  before.  It  will  also  be  found 
in  almost  all  cases  of  stricture,  that  the  subject  has  at  some  previous 
time  suffered  an  injury  at  childbirth,  urethritis,  or  something  to 
which  the  origin  of  the  stricture  can  be  traced.  Great  care  should 
be  taken  to  obtain  the  previous  history  of  cases  in  which  stricture 
is  suspected.     This  will  aid  in  settling  the  diagnosis  and  causation. 

Diagnosis. — A  digital  examination  by  the  vagina,  will  reveal 
thickening  and  induration,  if  the  stricture  is  due  to  that  cause. 
Cicatrices  of  the  vaginal  wall  compressing  the  urethra  can  be  de- 
tected in  the  same  way.  The  use  of  the  sound  will  aid  in  deter- 
mining the  location  of  the  stricture  and  the  extent  to  which  the 
canal  is  contracted.  When  the  stricture  is  at  the  meatus  it  can  be 
found  with  facility,  and  the  size  of  the  opening  can  be  measured 
with  equal  ease ;  but  when  it  is  located  higher  up,  the  largest  sound 
that  can  be  introduced  without  force  should  be  passed  up  to  the 
point  of  stricture.  This  will  localize  it ;  then,  by  using  a  sound  that 
will  pass  through  it,  the  extent  of  the  constriction  will  be  ascer- 
tained. 

The  affections  which  are  liable  to  be  mistaken  for  stricture  are 
retention  of  urine  or  difficult  urination  from  pressure  on  the  urethra 
by  the  displaced  gravid  uterus,  pelvic  tumors,  and  dislocations  of 
the  urethra.  The  former  can  be  excluded  by  a  vaginal  examination, 
and  the  latter  can  be  detected  by  the  sound,  used  as  I  directed  while 
discussing  the  diagnosis  of  the  dilatations. 

Prognosis. — Stricture  of  the  urethra  usually  yields  very  promptly 
to  treatment  so  that  the  prognosis  is  good.  The  only  exceptions  are 
where  the  stricture  has  existed  in  a  marked  degree  long  enough  to 
cause  dilatation  of  the  ureters  and  disease  of  the  kidneys.  Chronic 
cystitis  or  urethritis  occurring  as  a  result  of  the  stricture,  or  coinci- 
dent with  it,  may  so  complicate  matters  as  to  make  recovery  slow  or 
even  impossible.  In  cases  where  the  whole  urethra  is  contracted 
because  of  the  existence  of  a  vesico-vaginal  fistula  of  long  standing, 
there  may  be  found  extreme  difficulty  in  restoring  the  tissues  of 
the  urethral  walls  to  their  normal  state. 

Treatment. — The  treatment  of  stricture  will  depend  upon  its 


ORGANIC  DISEASES  OF  THE   URETHRA.  929 

location  and  cause.  If  it  is  situated  at  the  meatus,  it  can  be  divided 
by  the  urethrotome,  or  forcibly  stretcbed  with  the  dilator.  When 
due  to  bands  of  scar  tissue  in  the  vagina,  they  should  be  divided  at 
several  points,  and  the  urethra  dilated  by  passing  the  sound.  When 
it  is  owing  to  deposition  of  the  products  of  inflammation  in  the 
submucous  tissue,  forcible  and  rapid  dilatation,  as  practiced  on  the 
male  subject,  will  answer  well  if  the  proper  cases  for  this  form  of 
treatment  are  selected.  While  operating  in  this  way  the  dilatation 
should  be  made  carefully,  with  a  view  to  breaking  up  the  constiict- 
ing  tissue  without  lacerating  the  mucous  membrane.  To  do  this  it 
is  not  necessary  to  dilate  the  urethra  to  any  great  extent.  As  soon 
as  it  is  recognized  that  the  stricture  has  given  way,  the  dilatation 
should  be  suspended. 

Incising  the  stricture  from  within  outward,  according  to  the 
method  commended  by  Otis  and  others,  for  the  cure  of  stricture  in 
the  male,  will  no  doubt  answer  a  good  purpose.  In  fact,  I  am  in- 
clined to  believe  that  this  plan  of  treating  the  ajffection  is  the  best ; 
but  my  own  experience  with  this  operation  on  the  female  urethra  is 
not  sufficient  to  warrant  my  speaking  positively. 

In  contraction  of  the  w^iole  urethra,  arising  from  disuse  in  cases 
of  vesico-vaginal  fistula,  gradual  dilatation  with  graduated  sounds 
answers  very  well.  This  should  be  attended  to  before  closing  the 
opening  in  the  bladder.  In  all  cases,  attention  should  be  given  to 
any  inflammation  that  may  accompany  the  stricture  or  follow  the 
treatment.  It  is  well  also  to  keep  such  patients  under  observation 
and  pass  the  sound  from  time  to  time  to  see  if  there  is  any  ten- 
dency for  the  stricture  to  return. 

Stricture  at  the  Junction  of  the  Urethra  and  Bladder. — I  desire  to 
direct  special  attention  to  this  form  of  stricture  because  it  is,  so  far 
as  I  know,  peculiar  to  women,  and  its  influence  on  the  function  of 
the  bladder  has  not  been  pointed  out.  In  fact,  no  distinction  has 
been  made  between  the  pathology  or  clinical  history  of  stricture  at 
the  upper  end  of  the  urethra  and  elsewhere  in  the  canal.  At  least, 
I  am  not  aware  that  writers  on  this  subject  have  mentioned  this 
form  of  stricture.  My  own  observations  on  this  subject  have  been 
limited,  but  sufficient,  I  think,  to  warrant  me  in  saying  that  strict- 
ure does  occur  at  the  junction  of  the  bladder  and  urethra,  and  that 
it  behaves  differently  from  ordinary  stricture  at  other  parts  of  the 
canal. 

From  the  study  of  the  cases  which  have  come  under  my  notice, 
I  have  been  led  to  the  conclusion,  that  stricture  at  this  point  may  be 
produced  by  the  causes  which  give  rise  to  the  same  affection  else- 
60 


930  DISEASES  OF  WOMEN. 

where.  The  upper  portion  of  the  urethra  is  liable  to  the  same  trau- 
matic affections  and  inflammatory  troubles  as  the  rest  of  the  urinary 
organs ;  and  the  same  products  or  results  of  disease  which  cause 
stricture  of  the  other  portions  of  the  urethra  act  just  the  same  at 
the  point  in  question.  I  need  not,  therefore,  dwell  on  the  anatomi- 
cal lesions  found  in  this  affection.  The  point  of  most  importance 
to  which  I  desire  to  call  particular  attention  is  the  fact  that  stricture 
at  this  part  of  the  urethi'a  will  cause  dijfficuit  urination,  which  is 
out  of  proportion  to  the  extent  of  the  narrowing  of  the  canal.  In 
other  words,  thickening  of  the  tissues  at  the  union  of  the  urethra 
and  bladder,  with  contraction  of  the  canal  in  a  slight  degree,  will 
cause  great  difficulty  in  urination,  and  frequently  retention.  This  is 
contrai-y  to  the  history  of  strictm-e  of  the  urethra  at  other  points. 
In  such  cases  there  is  no  retention  of  urine  until  the  stricture  closes 
the  canal,  or  very  nearly  so  ;  but  I  have  seen  retention  in  cases  of 
stricture  at  the  neck  of  the  bladder  while  a  medium-sized  catheter 
could  be  passed  with  ease ;  thus  showing  that  the  narrowing  of  the 
canal  was  not  the  only  cause  of  the  deranged  function.  It  would 
appear  that  the  change  in  structure  of  the  tissues  prevented  the  nor- 
mal action  of  that  portion  of  the  canal  which  performs  the  function 
of  a  sphincter  vesicae.  In  discussing  the  anatomy  and  function  of 
the  bladder  and  urethra,  I  stated  that  the  process  of  closing  and 
opening  the  neck  of  the  bladder  was  not  fully  understood,  and  I 
must  acknowledge  a  like  difficulty  in  explaining  the  disturbance  of 
function  which  is  caused  by  partial  stricture  at  this  point.  Spas- 
modic stricture  suggests  itself  as  the  explanation  of  the  symptoms 
presented  in  such  cases ;  but  it  is  excluded  by  demonstrating  the 
presence  of  organic  narrowing  of  the  canal. 

Symptomatology. — The  symptoms  presented  in  this  form  of 
stricture  are  difficult  mination,  and  in  some  cases  complete  retention. 
I  have  also  noticed  in  one  case  that  there  was  a  frequent  desire  to 
urinate ;  but  that  was  accounted  for  by  a  slight  catarrh  of  the  blad- 
der. 

These  symptoms  are  such  as  occur  in  other  conditions,  such  as 
atrophy  and  paralysis  of  the  bladder;  obstruction  of  the  urethra 
from  tumors ;  calculi ;  or  the  pressure  of  the  displaced  uterus  and 
prolapsus  of  the  bladder.  The  affection  can  not,  therefore,  be  de- 
tected from  the  phenomena  presented. 

Diagnosis. — In  this  form  of  stricture  there  is  thickening  and 
induration  of  the  neck  of  the  bladder,  which  may  be  detected  by 
digital  examination  of  the  vagina.  The  sound  will  also  reveal  a 
narrowing  of  the  canal  at  the  vesical  neck,  but  the  contraction  may 


ORGANIC  DISEASES   OF  THE  URETHRA.  931 

not  be  marked.  Main  reliance  must  be  placed  upon  the  exclusion 
of  all  other  conditions  which  can  produce  the  same  symptoms. 
Pressure  upon  the  urethra  and  prolapsus  of  the  bladder  can  be  ex- 
cluded by  an  examination  of  the  pelvic  organs ;  and  the  use  of  the 
sound  will  show  anything  like  a  complete  obstruction  of  the  canal. 

Having  cleared  away  the  possible  existence  of  either  of  these 
conditions,  I  come  to  the  two  affections  which  are  most  likely  to  be 
confounded  with  this  form  of  stricture,  viz.,  atrophy  and  paralysis 
of  the  bladder.  To  distinguish  these  from  the  stricture,  the  cathe- 
ter should  be  passed  when  the  bladder  is  well  distended,  and  the 
character  of  the  flow  of  urine  watched,  when  it  will  be  observed 
that  in  stricture  the  urine  comes  away  with  the  usual  force.  The 
bladder  contracts  normally,  and  with  its  natural  vigor,  and  expels 
the  urine  in  a  well- sustained  stream  through  the  catheter  if  there  is 
stricture.  On  the  other  hand,  in  paralysis  and  atrophy,  the  stream 
is  slow  and  without  force,  so  much  so  that  voluntary  effort,  or  the 
pressure  of  the  hand  on  the  abdomen,  is  sometimes  necessary  to 
empty  the  bladder.  This  is  especially  so  when  the  catheter  is  used 
while  the  patient  is  in  the  recumbent  position.  Finally,  the  diag- 
nosis is  confirmed  by  testing  the  dilatability  of  the  urethra.  This 
can  be  done  by  passing  a  dilator  along  the  urethra,  and  gently  test- 
ing the  resistance  of  the  walls  of  the  canal.  In  this  way  a  slight 
yielding  can  be  observed  at  all  points  until  the  stricture  is  reached, 
and  then  decided  resistance  will  be  encountered.  By  careful  atten- 
tion to  these  points  in  the  investigation,  I  believe  it  will  be  possible 
to  make  a  diagnosis  with  reasonable  certainty. 

ILLUSTRATIVE    CASES. 

A  lady,  aged  thirty-two  ;  married  fourteen  years,  and  has  had 
three  children  ;  the  eldest  twelve  years  and  the  youngest  four,  years  of 
age.  Thirteen  years  ago  she  had  typhoid  fever,  and  during  the  fever 
had  retention  of  urine,  which  necessitated  the  us6  of  the  catheter 
for  about  two  weeks.  After  recovering,  she  was  able  to  empty  the 
bladder  without  difficulty,  but  she  suffered  from  frequent  and  pain- 
ful urination.  After  the  birth  of  her  second  child,  eight  years  ago, 
her  bladder  trouble  became  much  worse,  and  she  has  been  obliged  to 
use  the  catheter  almost  daily  ever  since.  When  comparatively  free 
from  pelvic  pain  and  tenderness  (a  relief  that  she  seldom  enjoys  ex- 
cept for  a  few  days  at  a  time)  she  can  empty  the  bladder  by  making 
strong  voluntary  efforts ;  but  the  rule  is  that  she  is  obliged  to  use 
the  catheter  about  every  four  or  Ave  hours.  The  bladder  and  ure- 
thra were,  upon  examination,  found  to  be  in  their  normal  positions, 


932  DISEASES  OF  WOMEN. 

but  there  were  thickening  and  induration  of  the  tissues  at  the  union 
of  the  urethra  and  bladdei*.  A  No.  10  (Eng.)  sound  passed  easily 
up  to  the  neck  of  the  bladder,  where  it  was  arrested.  A  No.  8 
(Eng.)  sound  was  then  used,  and  it  entered  the  bladder  after  encoun- 
tering a  little  resistance  at  the  point  named.  The  catheter  was  then 
introduced,  and  the  urine  flowed  freely  and  rapidly,  the  bladder  con- 
tracting promptly  and  with  its  normal  vigor.  While  the  instrument 
was  still  in  place,  a  vaginal  examination  by  the  linger  was  made,  and 
the  enlargement  and  induration  of  the  urethral  wall  were  distinctly 
felt.  Dilatation  of  the  urethra  was  then  tried,  and  the  canal  yielded 
readily  at  all  parts  except  at  its  extreme  upper  end,  where  it  was 
found  wanting  in  elasticity.  There  was  slight  catarrh  of  the  blad- 
der, as  shown  by  an  excess  of  mucus  in  the  urine.  The  urethra  was 
also  congested.  The  patient  was  very  weak,  nervous,  and  dyspeptic. 
She  was  put  upon  a  course  of  tonic  treatment,  and  the  canal  slowly 
dilated  by  passing  twice  a  week  graduated  conical  sounds,  each  one 
being  allowed  to  remain  in  place  for  five  or  ten  minutes  at  a  time. 
She  improved,  but  when  last  seen  she  still  had  difficulty  in  passing 
urine. 

Other  cases  might  be  given  from  my  own  records,  but  I  prefer 
to  present  one,  the  history  of  which  was  given  to  me  by  Dr.  Paul 
F.  Munde.  I  do  not  wish  it  to  be  understood  that  the  only  difficulty 
in  the  following  case  was  stricture  ;  I  only  desire  to  call  attention  to 
the  fact  that  the  patient  had  retention  of  urine  and  also  stricture  at 
the  neck  of  the  bladder.  Still  I  am  aware  that  the  retention  may 
have  been  due  to  some  other  cause — perhaps  paralysis  of  the  blad- 
der. There  are  some  points  in  the  history  of  the  case  which  do  not 
pertain  to  the  question  now  under  discussion,  but  I  will  give  the  full 
record  in  the  doctor's  own  words : 

"  Lizzie  C,  twenty-two  years  of  age,  single ;  admitted  to  the 
Woman's  Hospital,  December  27, 1876.  Menstruated  first  at  twelve. 
The  menses  since  have  been  irregular,  amount  small,  and  always 
with  pain  in  back  and  hypogastrium,  through  whole  flow  of  two 
days.  General  health  always  good  until  she  had  a  'bilious  attack' 
six  years  ago.  Four  years  ago  the  flow  became  more  and  more 
scanty,  and  finally  ceased  entirely  three  years  ago,  since  which  time 
she  has  not  menstruated  at  all.  Four  years  ago,  after  a  '  bihous 
attack,'  she  had  retention  of  urine  for  three  days,  at  which  time  the 
catheter  was  used.  She  had  several  attacks  of  retention  thereafter, 
at  intervals,  then  micturated  naturally  for  one  year,  but  for  the  past 
three  years  has  not  been  able  to  empty  her  bladder  without  the  aid  of 
a  catheter,  which  she  introduces  herself  habitually  three  times  in  the 


ORGANIC  DISEASES  OP  THE   UB^THRA.  933 

twenty-four  hours.  She  has  no  desire  to  micturate,  and  can  hold  her 
urine  twenty-four  hours  without  discomfort,  save  a  sliglit  sense  of 
distention.  She  lias  leucorrhoea.  Has  slight  menstrual  molimina 
every  four  weeks,  backache,  hypogastric  pain  and  soreness  in  breasts, 
constant  pelvic  weight  and  dragging.  Bowels  constipated.  General 
health  good.     There  is  now  frequent  nausea. 

"  Physical  Examination. — -There  is  anteflexion ;  depth  of  the 
uterus,  two  and  a  half  inches ;  both  ovaries  prolapsed  and  tender ; 
right  enlarged. 

"  Treatment. — Hot  vaginal  douche,  strychnia,  benzoic  acid  ;  later, 
daily  washing  out  of  the  bladder  with  acidulated  warm  water  (ac. 
muriat.  dil.,  gtt.  ij.  to  Oj).  Urine  contains  a  large  quantity  of  mucus 
and  triple  phosphates.  Washing  out  of  bladder  gives  no  relief. 
Phosphoric-acid  mixture  with  ergot  and  iron  was  given  for  months 
with  no  benefit.  Cups  to  lumbar  region ;  galvanic  current  through 
pelvis  twice  a  week. 

"February  3,  1877. — Bladder  washings  omitted,  as  they  caused 
pain.  Large  doses  of  ergot  were  given  for  two  months  (the  strychnia 
being  omitted  after  four  months'  trial),  but  without  benefit.  Faradic 
and  galvanic  current  also  used  alternately  every  day  for  months 
without  benefit.  Discharged  unimproved  in  any  way,  May  30, 
1877. 

"Readmitted,  October,  1877.  Condition  the  same. 
"October  31. — Urethra  dilated  under  ether;  finger  introduced 
into  bladder,  which  was  found  flaccid,  and  did  not  contract  on  the 
finger,  which,  however,  was  so  closely  constricted  at  the  sphincter 
vesicae  as  to  leave  a  circular  ring  on  the  finger,  the  distal  portion  of 
which  appeared  blue  and  almost  numb  on  being  withdrawn,  after 
about  five  minutes.  During  the  introduction  of  the  finger  the 
greatest  amount  of  opposition  felt  was  at  the  sphincter ;  therefore, 
tlie  supposition  was  expressed  that  the  retention  might  be  due  to 
spasmodic  contraction  of  the  sphincter  (hysterical  probably,  con- 
nected with  and  dependent  on  the  amenorrhoea,  or  deficient  pelvic 
innervation),  accompanied  by  atony  of  the  detrusor  from  the  same 
causes. 

"  On  examining  the  pelvic  cavity  with  the  finger  in  the  bladder, 
the  left  ovary  was  found  normal  in  position,  but  smaller  than  it 
should  be,  being  about  the  size  of  a  shelled  almond ;  the  right,  how- 
ever, was  distinctly  felt  as  a  globular  body  of  the  size  of  an  English 
walnut.  While  practicing  bimanual  palpation  on  this  ovary,  it 
suddenly  collapsed  under  the  fingers  and  entirely  disappeared,  and 
could  not  be  found  on  careful  palpation.     The  explanation,  doubt- 


934  DISEASES  OF  WOMEN. 

less,  is  that  a  cyst  had  been  ruptured,  and  a  partial  cause  at  least  for 
the  amenorrhoea  was  thus  discovered.  Peritonitic  symptoms  were 
feared,  and  ice  and  opium  given  ;  but,  save  some  suprapubic  sore- 
ness, no  inflammatory  reaction  followed.  Retention  persisted,  and 
urine  had  to  be  drawn  the  afternoon  of  the  dilatation. 

'"  November  9. — Goodman's  self-retaining  catheter,  with  rubber 
tubing  attached,  was  introduced  for  the  purpose  of  allowing  the 
urine  to  dribble  off  into  a  urinal,  and  thus  give  the  bladder  a  chance 
to  recover  its  tone.  But  the  catheter  caused  so  much  pain  that  it 
had  to  be  removed  after  several  days. 

"  November  19. — Soft-rubber  catheter  was  introduced,  with  tub- 
ing, etc.,  for  like  purpose,  and  is  now  retained  and  on  trial.  This 
also  caused  pain,  and  was  removed.  Subsequently  vaginal  cystotomy 
was  performed  by  Dr.  Emmet,  but  without  avail ;  and  the  patient, 
after  months  of  ineffectual  treatment,  was  finally  discharged  un- 
cured." 

Treatment. — Regarding  the  management  of  stricture  at  the 
junction  of  the  urethra  and  bladder,  I  am  obliged  to  say  that  my 
experience  has  not  yet  been  sufficient  to  enable  me  to  speak  definitely. 
It  will  be  seen  by  the  history  of  Dr.  Munde's  case  that  rapid  and 
free  dilatation  is  not  sufficient  to  effect  a  cure ;  at  least,  it  did  not 
relieve  his  patient.  Division  of  the  stricture  by  incision  suggests 
itself,  but  I  am  confident  that  that  operation  would  be  unsatisfactory, 
because  of  the  great  irritation  which  always  occurs  when  there  is  a 
solution  of  continuity  at  that  point.  My  practice,  therefore,  has 
been  to  produce  slow  and  gradual  dilatation  by  the  use  of  graduated 
sounds,  and  the  application  of  oleate  of  mercury  or  iodine  to  the 
anterior  vaginal  wall  at  the  site  of  the  stricture.  More  extended 
observation  may  develop  other  and  better  methods  of  treatment,  but 
for  the  present  this  is  all  that  I  have  to  offer  on  this  subject. 

9.  Foreign  Bodies  in  the  Urethra. — Having  treated  at  some  length 
the  subject  of  foreign  bodies  in  the  bladder,  I  shall  confine  myself 
here  chiefly  to  the  practical  points  relating  to  foreign  bodies  in  the 
urethra.  The  character  of  the  bodies  and  their  classification  are  the 
same  as  those  given  while  discussing  foreign  bodies  in  the  bladder. 

Sijmptomatology. — The  chief  symptom,  if  the  body  be  of  any 
size,  is  retention  of  urine.  In  some  cases  the  obstruction  is  complete, 
in  others  the  urine  comes  away  in  drops.  In  all  cases  there  is  pain 
and  spasmodic  action  of  both  the  bladder  and  urethra.  If  the  body 
be  rough  or  pointed,  it  will  injure  the  urethral  wall,  and  there  will 
usually  be  haemorrhage,  and  later,  inflammation,  possibly  peri-urethral 
abscess.    If  not  pointed,  but  hard  and  rough,  it  may  ulcerate  through 


ORGANIC  DISEASES  OF   THE  URETHRA.  935 

the  urethral  wall,  causing  considerable  hsemorrhage.  "When  the 
obstruction  is  kept  up  for  any  length  of  time,  the  greatly  distended 
bladder  becomes  very  painful,  and  may  be  felt  as  a  hard  tumor 
above  the  pubes. 

If  obstruction  occurring  from  this  cause  be  neglected,  such  in- 
juries of  the  bladder  and  kidneys  as  have  already  been  described 
will  ensue. 

Diagnosis. — The  pain  and  retention  will  lead  to  the  examination 
of  the  urethra,  first  by  catheter  or  sound,  and  then  by  the  finger  in 
the  vagina.  In  this  way  the  foreign  body  is  readily  detected,  un- 
less it  be  very  soft,  in  which  case  it  seldom  produces  retention, 
being  usually  washed  out  by  the  urine. 

Treatment. — The  foreign  body  being  detected,  its  extraction 
should  be  attempted  first  by  seizing  it  with  a  pair  of  long-bladed 
forceps,  keeping  it  firmly  in  place  by  a  finger  pressed  on  the 
urethra  through  the  vagina  behind  it.  If  this  is  not  successful,  an 
attempt  may  be  made  to  hook  it  out  with  a  wire  loop. 

I  have  seen  calculi  lodged  in  the  urethra  in  two  cases.  The  first 
one  was  detected  by  using  the  catheter  to  relieve  the  retention  of 
urine,  and  the  other  was  felt  through  the  vaginal  wall,  while  ex- 
ploring with  the  finger  to  determine  the  cause  of  the  pain  in  the 
urethra  and  the  inability  to  pass  water. 

The  first  one,  which  was  lodged  near  the  meatus,  was  removed 
as  follows  :  The  forefinger  of  the  left  hand  was  introduced  into  the 
yagina  and  pressed  above  the  calculus  to  steady  it.  A  wire  curette 
was  then  passed  beyond  the  stone  above,  and  by  making  traction 
with  the  curette  and  pressing  with  the  finger  from  above  downward, 
the  body  was  extracted. 

The  other  was  lodged  higher  up  in  the  urethra  and  was  removed 
by  the  same  method,  except  that  I  used  the  alligator  forceps  instead 
of  the  curette. 

If  it  can  not  otherwise  be  reached  the  urethra  may  be  dilated  up 
to  the  point  where  the  body  is  lodged,  and  then  extracted.  If  ex- 
traction is  impossible,  there  is  a  choice  of  cutting  into  the  urethra 
and  removing  it,  or  of  pushing  it  back  into  the  bladder  and  then 
performing  lithotripsy.     To  me  the  former  seems  preferable. 

10.  Incomplete  Internal  XTrethral  Fistula. — This  is  one  of  the 
rather  rare  affections,  but  it  deserves  a  brief  notice  here,  because 
little  if  anything,  is  said  about  it  in  the  books,  and  it  will  be  very 
likely  met  with  at  some  time  in  the  practice  of  every  physician. 

The  pathology  is  pretty  clearly  indicated  by  the  name.  It  is 
simply  an  opening  in  the  urethra  which  leads  into  the  walls  of  the 


936  DISEASES  OF  WOMEN. 

urethro-vaginal  septum,  but  does  not  open  into  the  vagina.  It  is 
the  result  of  some  pre-existing  trouble. 

The  causes  which  produced  this  affection  in  the  cases  which  I 
have  seen  (I  recall  only  two  that  have  come  under  my  notice)  were, 
in  the  iirst,  a  jDeri-urethral  inflanunation  which  suppurated  and  dis- 
charged into  the  urethra,  and  in  the  second,  a  cyst  which  formed  in 
the  urethro-vaginal  septum,  which  also  opened  into  the  urethra.  In 
the  first  case,  I  suspect  that  the  patient  had  gonorrhoea  during  preg- 
nancy, and  that  after  confinement  an  abscess  formed  in  the  anterior 
vaginal  wall,  and  opened  into  the  urethra  as  I  have  already  stated. 
The  walls  of  the  abscess  contracted,  but  instead  of  healing  com- 
pletely, there  remained  a  sinus  which  communicated  with  the 
urethra.  Tliis  much  was  inferred  from  the  history  obtained  regard- 
ing its  origin.  When  she  was  first  seen,  the  fistulous  opening  was 
found  in  the  floor  of  the  urethra,  and  it  led  into  the  thickened  and 
indurated  septum  between  the  urethra  and  vagina. 

The  other  case  was  developed  under  my  own  observation  in  the 
following  way.  The  lady  was  pregnant,  and  during  pregnancy 
observed  that  there  was  some  enlargement  just  within  the  introitus 
vaginse.  On  examination,  a  cyst  was  found  in  the  anterior  vaginal 
wall  at  the  middle  of  the  urethra.  She  was  at  the  eighth  month  of 
utero-gestation  when  this  diagnosis  was  made,  and  I  decided  to  let 
the  matter  rest  until  her  confinement.  Immediately  after  the  birth 
of  her  child,  inflammation  was  set  up  in  the  cyst,  and  suppuration 
followed.  An  opening  was  made  into  the  cyst  from  the  vagina, 
and  pus  was  freely  discharged.  At  the  same  time  pus  began  to  flow 
from  the  urethra.  The  discharge  continued  from  both  openings 
for  some  time,  and  then  the  vaginal  opening  closed,  but  pus  con- 
tinued to  flow  from  the  urethra  for  many  weeks.  A  probe  could  be 
passed  from  the  fistulous  opening  in  the  urethra  into  the  sac,  which 
slowly  contracted,  and  finally,  at  the  end  of  six  months,  closed  en- 
tirely, and  the  patient  completely  recovered. 

Symptomatology. — There  is  pain  during  urination,  and  heat  and 
aching  disti'ess  in  the  urethra ;  and  if  the  opening  is  near  to  the 
neck  of  the  bladder,  frequent  urination  and  vesical  tenesmus.  Pus 
is  discharged  from  the  urethra  during  urination,  and  is  found  in  the 
urine.  It  also  oozes  away  at  all  times.  In  some  cases,  the  urine 
enters  the  fistula  and  causes  smarting,  burning  pain  during  and  for 
some  time  after  urination,  by  distending  the  sac  or  burrowing  in  the 
tissues. 

Diagnosis. — Examining  the  vagina  by  the  finger  will  detect  the 
thickening  and  induration  of  the  walls  of  the  urethra  and  vagina  at 


ORGANIC  DISEASES  OF   THE   URETHRA.  937 

the  seat  of  tlie  fistula  ;  and  by  making  pressure  with  the  finger  from 
above  do^v^lward,  pus  and  urine  can  be  pressed  out,  and  may  be 
seen  as  they  escape  from  the  meatus  urinarius.  A  small  probe  with 
a  bulbous  point  should  be  bent,  so  as  to  make  a  short  curve  at  the 
end,  and  then  passed  into  the  urethra  with  the  curve  directed  toward 
the  floor  of  the  canal ;  and  by  njoving  it  to  and  fro  the  fistula  can 
usually  be  found.  The  point  of  the  probe  will  catch  in  the  open- 
ing, and  when  carried  downward  it  can  be  felt  through  the  wall  of 
the  vagina. 

The  only  condition  which  is  liable  to  be  confounded  with  fistula 
is  urethrocele,  but  by  keeping  in  mind  the  physical  signs  of  that  af- 
fection the  distinction  will  be  recognized.  Should  there  be  any 
doubt,  the  endoscope  should  be  used  to  examine  the  urethra.  The 
fistula  will  then  be  found,  and  by  using  the  speculum  the  opening 
can  be  probed  through  it.  A  flexible  gum  catheter  may  be  used  if 
the  silver  probe  does  not  succeed. 

Ti'eatment. — The  cases  that  have  come  under  my  care  were 
treated  by  washing  out  the  urethra  with  warm  water  and  borax  sev- 
eral times  a  day,  and  keeping  the  sac  emptied  as  completely  as  pos- 
sible by  making  pressure  on  the  urethra,  through  the  vagina,  with 
the  finger.  Both  cases  were  very  tedious,  and  required  much  care 
and  long  treatment.  This  experience  has  satisfied  me  that  the  man- 
agement of  such  cases  ought  to  be  altogether  different  from  that 
which  I  employed.  I  am  con ti dent  that  better  and  more  prompt 
results  would  be  obtained  by  converting  the  incomplete  into  a  co'm- 
plete  fistula.  This  could  be  easily  accomplished  by  passing  a  probe 
into  the  opening  as  far  as  possible,  and  then  cutting  down  upon  it 
through  the  wall  of  the  vagina.  By  this  operation  a  urethro-vaginal 
fistula  is  made,  which  by  proper  treatment  will  close  of  its  own  ac- 
cord. During  the  after  treatment  the  patient  should  wear  a  self- 
retaining  catheter,  or,  what  is  still  better,  have  the  bladder  emptied 
regularly  by  the  catheter.  This  will  keep  the  urine  from  getting 
into  the  fistula,  which  prevents  healing.  Care  should  be  taken  to 
keep  the  opening  in  the  vagina  from  uniting  before  the  urethral 
opening  is  healed.  This  can  be  accomplished  by  passing  the  probe 
into  it  from  time  to  time.  The  whole  fistula  should  be  kept  clean 
by  injecting  water  into  the  urethra  and  letting  it  flow  through  the 
fistula  into  the  vagina.  In  case  the  tissues  are  so  indurated  and 
changed  in  character  as  to  refuse  to  heal  under  this  treatment,  the 
fistula  must  be  closed  by  the  usual  operation.  The  method  of  oper- 
ating is  the  same  as  in  vesico- vaginal  fistula,  a  description  of  which 
will  be  hereafter  given. 


CHAPTEK  LI. 

DISEASES   OF   THE    GLANDS    OF   THE    FEMALE   URETHRA. 

The  diseases  of  these  glands  to  which  I  invite  attention  are ; 

1.  Subacute  inflammation  or  catarrh. 

2.  Gonorrhoea!  inflammation  and  its  results  or  productSo 

3.  Inflammation  following  vulvitis  such  as  occurs  in  strumous 
children. 

4.  Tuberculosis. 

1.  Catarrhal  Inflammation. — The  first  affection  named  in  the  classi- 
fication is  a  mild  form  of  inflammation  which  occurs  in  connection 
with  subacute  vaginitis,  such  as  we  find  accompanying  ordinary  uter- 
ine disease,  or  following  parturition.  This  condition  gives  the  patient 
very  little,  if  any,  inconvenience,  and  readily  passes  unnoticed  by  the 
gynecologist  unless  specially  looked  for.  The  mouths  of  the  ducts 
are  slightly  enlarged,  and  sometimes  surrounded  by  a  very  narrow 
areola  of  a  bright  red  color.  By  pressure  upon  the  urethra  from  be- 
hind forward  they  discharge  a  white  serous  fluid.  The  cases  which 
have  come  under  my  observation  were  detected  while  examining  for 
other  diseases,  and  none  of  them  was  attended  with  any  marked 
symptoms.  In  some  of  them  the  inflammation  disappeared  without 
treatment.  In  others  it  continued  without  showing  any  tendency 
to  increase  in  severity  or  lead  to  important  changes  of  structure.  It 
is  quite  possible  that  a  non-specific  vaginitis  might  induce  a  high 
grade  of  inflammation  in  these  glands,  with  all  the  pathological 
changes  to  be  described  hereafter,  but  up  to  the  present  time  I  liave 
not  observed  any  evidence  tliat  such  is  the  case. 

2.  Gonorrhceal  Inflammation. — This  is  of  the  chronic  purulent 
variety,  and  in  time  extends  from  the  mucous  membrane  of  the 
ducts  to  the  surrounding  tissues.  It  does  not  usually  attract  atten- 
tion until  the  vaginitis  and  uretliritis  have  subsided. 

The  lesions  presented  differ  according  to  the  length  of  time  which 
the  disease  has   existed.     AVhen  examined  early  there  is  a   slight 

938 


DISEASES  OF  THE   GLANDS  OF  THE  FEMALE   URETHRA.     939 

swelling  of  the  lower  portion  of  the  urethra.  The  mouths  of  the 
ducts  are  larger  than  normal,  and  the  tissues  around  them  are  con- 
gested. There  is  tenderness  to  the  toucli,  and  pressure  upon  the 
urethra  from  above  downward  causes  a  free  purulent  discharge. 
Sometimes  it  is  necessary  to  separate  the  labia  of  the  meatus  in  order 
to  see  the  orifices  of  the  ducts.  In  cases  of  longer  standing  the 
mouths  of  the  ducts  are  brought  into  view  by  a  slight  prolapsus  and 
eversion  of  the  mucous  membrane  caused  bv  swelling.  The  mucous 
membrane  in  the  neighborhood  of  the  ducts  becomes  thickened  by 
proliferation  of  the  areolar  tissue  and  epithelium,  presenting  an  ir- 
regular papillomatous  appearance  of  a  deep-red  color,  upon  the  inner 
sides  of  which  the  orifices  of  the  ducts  appear  like  minute  ulcers, 
of  a  yellowish  gray  color.  The  lower  third  of  the  urethra  is  gener- 
ally thickened  and  indurated.  The  general  appearance  of  the  j)arts  is 
quite  like  caruncle  or  papilloma  of  the  meatus.  In  fact,  inflamma- 
tion of  these  glands  has  been  mistaken  for  caruncle,  at  least  it  has 
been  my  misfortune  in  the  past  to  confound  the  two  affections,  and 
1  can  not  see  how  others  could  have  made  a  differential  diagnosis,  if 
guided  by  the  current  literature  upon  the  subject.  In  a  large  propor- 
tion of  the  cases  of  this  disease  I  have  observed  that  upon  the  inner 
sides  of  the  labia  minora,  which  rest  upon  the  meatus,  there  are  patches 
of  inflammation  which  are  caused  and  kept  up  by  the  purulent  dis- 
charge from  the  glands.  These  circumscribed  patches  of  inflamma- 
tion sometimes  extend  downward  on  each  side  of  the  introitus,  and 
occasionally  involve  the  carunculse  myrtiformes.  This  gives  rise  to 
much  tenderness,  which  simulates  vaginismus.  The  chief  symptoms 
are  extreme  tenderness  to  the  touch,  great  discomfort  in  sitting  and 
walking,  occasional  sharp  stinging  pain,  and  a  continual  sense  of 
heat  in  the  parts.  There  is  painful  urination  in  some  cases,  and  in 
others  there  is  not.  In  some  of  the  most  marked  cases  that  I  have 
seen,  this  symptom  was  entirely  absent,  while  in  less  severe  forms  it 
has  been  present.  That  peculiar  difference  in  the  history  of  cases  I 
have  attributed  to  the  fact  that,  in  the  well-developed  forms  of  the 
disease  there  is  a  considerable  eversion  of  the  lower  portion  of  the 
urethra,  which  throws  the  diseased  and  tender  portion  outward,  and 
thereby  prevents  the  urine  from  coming  in  contact  with  the  irritable 
surfaces.  Occasionally  there  is  frequent  urination,  due  probably 
to  sympathetic  irritation  of  the  bladder.  The  symptom  which  is 
always  present,  in  varying  degrees  of  severity,  is  tenderness.  The 
diagnosis  and  treatment  may  be  left  unnoticed  until  the  other  two 
affections  of  these  glands  have  been  described. 

3.  Purulent  Vulvitis. — This  occurs  in  children,  especially  those  of  a 


940  DISEASES  OF  WOMEN. 

scrofulous  diathesis,  and  occasionally  extends  to  the  urethral  glands. 
When  such  an  extension  of  the  disease  occurs,  it  adds  to  its  well-known 
rebeUiousness  to  treatment.  The  original  inflammation  of  the  vulva 
may  be  relieved,  but  if  the  glands  are  involved,  the  purulent  dis- 
charge from  them  will  soon  light  up  the  disease  of  the  external 
parts.  From  my  own  observations  I  believe  that  these  glands  rarely 
become  involved  ;  but  when  they  do,  there  is  little  possibility  of 
curing  the  affection  of  the  vulva  until  the  glands  are  first  successful- 
ly treated.  There  is  really  nothing  peculiar  in  the  cHnical  history 
of  this  form  of  disease,  except  its  etiology,  and  therefore  I  need  not 
dwell  longer  upon  it  further  than  to  say  that  I  have  seen  a  case  of 
this  kind,  which  had  resisted  treatment  for  a  long  time,  but  prompt- 
ly recovered  after  the  inflammation  of  the  glands  was  detected  and 
treated, 

4,  Tuberculosis,  or  Tubercular  Inflammatioii  of  the  Urethral  Glands. 
— This  is  an  affection  to  be  distinguished  from  the  other  forms  of  the 
disease  already  considered.  It  occurs  only  in  those  who  are  of  thfr 
tubercular  diathesis,  and  may  appear  as  a  primary  affection,  or  be 
developed  during  the  progress  of  tubercular  disease  of  other  organs 
of  the  body.  When  the  disease  is  first  established,  it  presents  th& 
same  pathological  appearance  as  has  been  described  under  the  head 
of  gonorrhoeal  inflammation.  There  is,  apparently,  the  same  purulent 
discharge,  with  redness  and  proliferation  around  the  mouths  of  the 
ducts,  giving  the  peculiar  caruncular  or  papillomatous  appearance. 
The  only  peculiar  characteristics  of  this  affection  that  have  been  ob- 
served up  to  the  present  time,  are  the  accumulation  of  caseous  ma- 
terial in  the  tubules  and  ulceration,  which  occur  in  more  advanced 
stages  of  the  disease. 

The  ulceration  takes  place  in  the  newly-formed  tissue  in  the 
walls  and  around  the  mouths  of  the  tubules.  These  caseous  con- 
cretions and  ulcerations  are  not  found  in  all  cases.  Indeed,  they  are 
rare. 

There  is  generally  urethral  inflammation  accompanying  this  con- 
dition of  the  glands.  It  sometimes  begins  simultaneously  with  the 
disease  of  the  glands,  and  when  it  does  not  it  follows  soon  after.  In 
time  the  bladder  becomes  affected,  and  also  the  kidneys.  At  what- 
ever point  the  disease  commences  it  increases  in  severity,  and  ex- 
tends until  the  whole  of  the  urinary  organs  are  involved,  unless  the 
patient  succumbs  before  it  has  completed  its  progress.  In  some 
cases  there  are  polypi  and  papillary  growths  of  small  size  found 
along  the  urethra.  These,  I  believe,  originate  in  inflammation  of 
mucous  follicles  and  papillsB  of  the  mucous  membrane. 


DISEASES   OF  THE   GLANDS  OF  THE  FEMALE  URETHRA.     941 

The  symptoms  presented  in  this  form  of  disease  are  the  same  as 
those  found  in  the  other  forms  ah-eady  described.  From  this  it  will 
be  observed  that  the  physical  appearance  and  the  symptoms  are  in- 
sufficient to  establish  a  diagnosis.  When  there  are  ulcerations  and 
caseous  deposits  the  disease  may  be  strongly  suspected  of  being  tu- 
bercular. Still,  there  is  room  for  doubt  until  we  find  tuberculosis  of 
other  organs.  This  either  precedes  or  soon  follows  the  appearance 
of  the  disease  of  the  glands. 

In  all  the  cases  which  have  come  under  my  observation,  the 
lungs  were  either  tubercular  when  the  patients  were  first  seen  or 
became  so  soon  after. 

This  affection  is  a  source  of  great  annoyance  and  suffering,  and 
no  doubt  hastens  the  progress  of  the  pulmonary  disease,  with  which 
it  is  generally  accompanied.  It  has  also  another  very  important 
significance  in  the  fact  that  it  indicates  the  commencement  of  gen- 
eral tuberculosis  of  the  urinary  organs.  The  diagnosis  of  tubercular 
cystitis  and  urethritis  has  always  been  exceedingly  difficult  in  the 
early  stages  of  the  disease.  Indeed,  it  has  been  deemed  imiDossible 
by  most  authors  to  distinguish  ordinary  cystitis  from  the  tubercular 
form  until  the  disease  became  developed  in  other  organs  of  the 
body.  Now  the  tuberculosis  of  these  glands  is  understood,  a  valu- 
able aid  to  diagnosis  has  been  gained.  Whenever  an  inflammation 
of  these  glands  is  found  that  can  not  be  traced  to  a  former  gon- 
orrhoea or  vulvitis,  it  is  almost  sure  to  be  tubercular,  and  the 
diagnosis  is  placed  beyond  doubt  if  the  patient  has  the  tubercular 
diathesis. 

I  am  greatly  indebted  to  Dr.  Terrillon,  of  Paris,  for  some  very 
valuable  information  upon  the  relations  of  disease  of  these  glands 
to  tuberculosis.  In  the  "  Progres  Medicale "  he  published  a  very 
elaborate  article  entitled  "Polypoid  Excrescences  of  the  Female 
Urethra,  Symptomatic  of  Tuberculosis  of  the  Urinary  Organs,"  which 
is  full  of  original  observations  of  inestimable  value.  In  comparing 
his  observations  with  my  own,  I  am  fully  satisfied  that  he  has  mis- 
taken tubercular  inflammation,  and  the  products  of  these  glands,  for 
excrescences,  in  some  of  his  cases  at  least.  Without  being  aware  of 
the  presence  of  these  glands,  it  is  perfectly  natural  that  he  should 
class  those  vascular  developments  found  at  the  meatus  urinarius 
among  the  ordinary  neoplasms  of  the  urethra,  just  as  all  others  have 
done  in  the  past.  There  is  every  reason  for  believing  that  the  ex- 
crescences which  Dr.  Terrillon  refers  to  differ  in  their  essential  pa- 
thology from  the  ordinary  polypoid  growths,  usually  called  carun- 
culae,  which,  are  found  in  the  urethra  and  are  not  associated  with 


942  DISEASES   OF  WOMEN. 

tuberculosis.  And  as  the  history  of  his  cases  coincides  with  the  his- 
tory of  the  cases  of  tuberculosis  of  these  glands  which  I  have  seen, 
I  am  compelled  to  believe  that  he  has  not  fully  comprehended  the 
true  pathology  of  this  aJfection.  He  has,  however,  clearly  shown 
its  relation  to  tuberculosis  of  the  urinary  organs,  and  that  alone  is 
worthy  of  the  highest  honor. 

Dr.  Terrillon's  article  is  too  long  to  be  given  in  full,  but  a  few 
condensed  extracts  will  show  his  views  upon  the  subject.  His 
description  of  the  symptoms  and  the  general  appearance  of  the 
parts  affected  is  so  complete  that  I  will  give  it  in  his  own 
words : 

"  The  fungoid  growths  show  themselves  usually  at  the  surface 
of  the  urethral  orifice.  They  are  projecting  and  pedunculate.  Sel- 
dom isolated,  they  form  most  frequently  a  wreath  more  or  less  regu- 
lar, around  the  orifice  of  the  meatus.  In  yery  aggravated  cases  they 
are  united  into  a  mass,  and  then  form  a  real  projecting  tumor  with 
a  fringed  aspect,  of  a  lively  red.  In  the  center  of  the  tumor  is  easily 
to  be  found  the  orifice  of  the  urethra  masked  by  those  papillary 
growths.  The  clinical  history  of  fungoid  excrescences  of  the  urethra 
accompanying  tuberculosis  of  that  organ  and  the  bladder  includes 
the  observation  of  two  distinct  parts :  First,  the  study  of  the  growths 
themselves  and  the  character  of  them ;  second,  all  the  phenomena  to 
be  found  in  cystitis  and  tubercular  urethritis.  Sometimes  the  symp- 
toms of  the  two  lesions  are  found  together ;  sometimes  on  the  con- 
trary, they  exist  singly  up  to  a  certain  period  of  the  disease.  One 
of  the  special  symptoms  of  this  affection  is  the  exquisite  tenderness 
of  which  these  fungoids  are  possessed.  The  least  touch,  the  least 
rubbing,  the  passage  of  urine,  sufiices  to  cause  the  most  extensive 
pain,  which  renders  life  insupportable.  This  hypersesthesia,  which 
may  extend  to  the  neighboring  parts,  causes,  at  the  sides  of  the  ori- 
fice of  the  vulva,  symptoms  of  the  most  acute  vaginitis.  These  are 
the  ordinary  symptoms  of  fungoid  growths  when  existing  exter- 
nally." The  author  at  this  point  refers  to  excrescences  found 
within  the  urethra  as  being  of  the  same  nature  as  those  found  at  the 
meatus.  He  makes  no  distinction  between  the  two  forms  of  disease. 
There  is,  however,  a  difference  w^orthy  of  notice.  Excrescences 
found  within  the  urethra  are  usually  cystic  polypi  or  enlarged  pa- 
pillae of  the  mucous  membrane,  conditions  which  may  exist  inde- 
pendently of  tuberculosis.  I  infer  from  some  other  statements  made 
in  his  writings  that  the  granular  urethritis — as  we  are  in  the  habit 
of  calUng  it — is  generally  secondary  to  the  disease  of  the  urethral 
glands.     The  views  of  this  author  in  regard  to  the  order  of  develop- 


DISEASES  OP  THE  GLANDS  OF   THE  FEMALE  URETHRA,     943 

ment  of  iiretliritis,  cystitis,  and  finally  tuberculosis  of  the  lungs,  are 
set  forth  in  the  following: 

"  Sometimes  at  the  time  of  their  appearance  these  fungoids  ap- 
pear to  be  altogether  isolated  from  all  other  serious  lesions.  Yet 
they  seem  to  precede  tuberculization,  or  soon  take  a  rapid  course  in 
developing  granulations  in  the  urethra.  In  other  cases  these  growths 
may  appear  some  time  after  the  symptoms  of  tuberculization  have 
been  established,"  The  cases  recorded  by  Dr,  Terrillon,  and  also 
those  which  have  come  under  my  o^vn  observation,  show  that,  as  a 
rule,  this  disease  of  the  urethra  precedes  the  appearance  of  tuber- 
culosis in  other  organs  of  the  body,  such  as  the  lungs.  It  also  is 
one  of  the  first  lesions  observed  in  tuberculosis  of  the  urinary  organs. 
The  following  is  from  Dr,  Terrillon's  paper  on  this  part  of  the  sub- 
ject : 

"IS^ow  comes  up  the  important  question  whether  these  polypi  of 
the  mucous  membrane  should  be  considered  as  a  jDrimary  or  an  idio- 
pathic lesion,  and  I  think  that  it  can  be  solved  in  the  following  man- 
ner :  These  polypi  are  most  assuredly  the  result  of  chronic  inflamma- 
tion and  an  irritation  of  the  mucous  membrane.  Now,  development 
of  tubercular  granulations  within  the  mucous  membrane  is  at  first 
the  cause  of  irritation,  before  any  changes  in  the  urine ;  ulceration 
does  not  occur  until  after  a  sufficient  length  of  time.  With  one  of 
our  patients  the  first  irritation  induced  the  fonnation  of  polypi,  and 
the  common  painful  symptoms  followed.  Their  extirpation  gave 
relief,  but  that  lasted  only  up  to  the  time  when  urethro- vesical  ulcera- 
tion occurred.  It  will  be  observed  that  in  this  case  the  affection 
began  in  the  urethra  and  extended  to  the  bladder,  and  also  second- 
arily involved  the  left  kidney  (ascending  tuberculosis),  causing, 
finally,  change  in  the  urine,  with  the  free  formation  of  pus.  I  there- 
fore do  not  hesitate  to  maintain  that  the  fungoid  polypi  are  the  result 
of  tubercular  irritation  of  the  mucous  membrane  of  the  urethra, 
which  gives  rise  to  the  very  serious  symptoms  which  occur  in  the 
early  stages  of  the  disease.  Without  them,  urinary  tuberculosis 
would  not  give  rise  to  those  striking  symptoms  until  after  a  sufficient 
length  of  time,  when  the  ulcerations  appear  in  other  organs.  An 
analogous  phenomenon  which  is  observed  in  the  larynx  should  be 
mentioned  here.  We  know,  as  a  matter  of  fact,  that  the  tuberculiza- 
tion of  the  larynx  does  not  only  occasion  ulceration,  but  also  poly 
poid  growths.  There  is  produced  at  the  expense  of  the  ulcerated 
mucous  membrane  an  hypertroj)hy  and  proliferation,  in  the  form 
of  cauliflower  excrescences  or  cockscomb  growths,  a  species  of 
polypi,  smaller  or  larger,  by  which  the  glottis  might  be  more  or  less 


944  DISEASES  OF  WOMEN. 

obliterated.  It  will,  therefore,  be  admitted  that  there  is  a  resem- 
blance between  laryngeal  excrescences  and  those  found  in  the  ure- 
thra of  women.  The  polypoid  excrescences  of  the  female  urethra 
are  shown,  from  an  etiological  point  of  view,  to  be  of  two  distinct  va- 
rieties. The  iirst  variety  is  idiopathic,  and  may  be  recognized  by  a 
slight  irritation.  The  prognosis  is  good ;  extirpation  in  these  cases 
gives  a  rapid  cure.  This  is  the  most  frequent  variety.  The  second 
kind,  although  they  give  the  same  outward  appearance  as  the  first 
variety,  are,  on  the  contrary,  accompanied  from  the  outset  by  ure- 
thritis and  tubercular  cystitis,  of  which  variety  these  lesions  consti- 
tute important  symptoms." 

It  is  clearly  evident  to  me  that  the  two  varieties  described  by 
Dr.  Terrillon  differ  very  essentially  in  their  pathology.  The  first, 
or  simpler  forms  correspond  to  the  papilloma  occasionally  seen,  and 
so  easily  cured  by  extirpation.  The  other  variety  has  its  origin  in 
tubercular  disease  of  the  urethral  glands,  and  is  incurable  by  any 
treatment  heretofore  known,  as  the  author  states. 

Dr.  Terrillon  gives  the  full  history  of  four  cases  observed  by 
him.  They  are  original,  and  of  great  value,  but  too  long  to  be  pro- 
duced here.  Suffice  it  to  say,  that  in  all  four  there  were  present  the 
excrescences  at  the  meatus  urinarius,  due,  as  their  clinical  histories 
show,  to  disease  of  the  glands,  and,  finally,  tuberculosis  of  the  ure- 
thra, bladder,  and  lungs,  A  careful  post-mortem  examination  was 
made  in  the  fourth  case  observed,  which  revealed  tuberculosis  of  the 
urethra,  bladder,  right  kidney,  and  lungs. 

Wlien  I  found  infiamniation  of  these  glands  associated  with  tuber- 
culosis of  other  organs,  it  occurred  to  me  that  the  disease  of  the  glands 
might  be  of  the  same  nature,  or  tubercular ;  but  I  am  indebted  to 
the  writings  of  Dr.  Terrillon  for  the  full  knowledge  of  the  patho- 
logical relations  of  the  affection  of  these  glands  to  tubei'culosis  of  the 
other  urinary  organs.  We  have  studied  the  subject  from  different 
stand-points,  and  the  combined  results  of  our  labors  cover  the  ground 
pretty  thoroughly.  While  he  has  clearly  settled  the  relation  of  these 
excrescences  to  tuberculosis  of  the  urinary  organs,  I  have  satisfied 
myself  that  these  new  growths  are  but  the  products  of  a  tubercular 
infiammation  of  the  urethral  glands,  the  existence  of  which  were,  I 
presume,  unknown  to  him.  The  treatment  of  the  various  forms  of 
inflammation  of  these  glands  may  all  be  discussed  at  the  same  time. 

It  is  settled  upon  the  best  evidence  that  when  these  glands  be- 
come inflamed  there  is  no  natural  tendency  to  their  recovery.  Those 
who  have  read  the  history  of  my  first  published  case  will  remember 
that  I  employed  all  the  recognized  treatment  for  caruncle,  but  at  the 


DISEASES  OF  THE  GLANDS   OF   THE  FEMALE  URETHRA.     945 

end  of  a  year  my  patient  M'as  no  better.  Dr.  Terrillon  has  had  a 
similar  experience.  On  this  point  he  says  :  "  A  characteristic  more 
important,  and  to  which  I  desire  to  call  especial  attention,  because 
it  indicates  well,  in  my  opinion,  the  consecutive  development  of  these 
excrescences,  is  their  tenacity  and  the  facility  with  which  they  recur. 
Really,  one  can  see  in  the  observations "  (meaning  his  cases)  "  in 
which  continued  surgical  intervention  has  been  practiced,  it  brought 
about  either  no  relief  or  only  a  momentary  amelioration." 

The  treatment  which  I  employed  at  first  was  to  inject  the  tu- 
bules with  the  ordinary  solutions  used  in  the  treatment  of  inflam- 
mation of  mucous  membranes,  using  for  the  purpose  a  hypodermic 
syringe,  with  the  point  of  the  needle  rounded  off.  This  method  I 
found  useful  but  very  tedious.  It  then  occurred  to  me  that  laying 
oj)en  the  tubules  their  whole  length  and  keeping  them  open  would 
prevent  the  purulent  accumulation  (which  acts  so  effectually  in  keep- 
ing up  the  inflammation),  and  also  bring  the  affected  parts  within 
easy  reach  of  the  necessary  treatment.  This  method  was  suggested 
in  my  paper,  published  seven  years  ago,  and  since  then  I  have  tried 
the  method  in  quite  a  number  of  cases,  and  found  it  entirely  satis- 
factory. In  the  majority  of  cases  it  is  ail  that  is  required  to  effect 
a  complete  cure.  The  method  of  operating  is  as  follows :  The  pa- 
tient is  placed  upon  the  left  side,  and  a  Suns's  speculum  used  to  keep 
the  labia  apart  and  retract  the  perinceum.  This  brings  the  j)arts 
well  into  view,  and  within  easy  reach  of  the  operator. 

The  position  and  depth  of  the  tubules  having  been  first  ascer- 
tained, the  probe-pointed  blade  of  a  very  fine  scissors  is  then  intro- 
duced, and  the  posterior  wall  divided  its  whole  length.  To  prevent 
the  parts  from  reuniting,  a  small  piece  of  cotton,  saturated  with 
persulphate  of  iron,  should  be  packed  in  between  the  divided  edges. 
Brushing  the  surfaces  over  with  the  iron,  without  using  the  cotton, 
will  answer,  although  less  certainly,  to  prevent  reuniting.  Later 
still  in  my  practice  I  have  opened  these  ducts  with  the  cautery. 
The  method  is  as  follows  :  A  probe  is  passed  into  the  ducts,  and  the 
wall  to  be  divided  is  made  tense  by  making  pressure  outward  with 
the  probe.  The  tissues  are  then  divided.  This  method  has  the  ad- 
vantages of  preventing  haemorrhage,  and  also  of  preventing  the 
parts  from  reuniting.  Yery  little  after  treatment  is  required.  In 
the  majority  of  cases  recovery  follows  the  operation  of  laying  open 
the  canals.  Sometimes  the  inflammation  lingers  in  a  modified  form, 
but  yields  to  a  few  applications  of  nitrate  of  silver  or  sulphate  of 
zinc.  In  several  eases  in  which  the  excrescences  were  abundant, 
they  remained  after  the  operation,  although  very  much  reduced  ir 
61 


946  DISEASES  OF  WOMEN. 

size.     An  application  of  nitric  acid  destroyed  tliem,  and  they  have 
not  sho\vn  the  least  disposition  to  return. 

ILLIJSTEATrV'E   CASES. 

Gonorrhoeal  Inflammatioii. — The  patient  was  a  married  lady,  thirty 
years  of  age.  She  was  well  developed,  and  had  always  enjoyed 
good  general  health.  "With  the  exception  of  a  mild  form  of  dys- 
menorrhoea,  she  had  had  no  disease  of  the  sexual  organs  until  one 
year  before  she  came  under  my  observation.  At  that  time  she  was 
abruptly  attacked  with  a  profuse  leucorrhoea  and  other  symptoms  of 
inflammation  of  the  vulva  and  vagina,  including  painful  urination. 
She  placed  herself  at  once  under  the  care  of  the  family  physician, 
who  treated  her  locally  until  she  came  to  me.  Her  leucorrboea  had 
by  that  time  diminished,  and  the  painful  urination  had  passed  away, 
but  otherwise  she  had  not  improved.  At  my  first  examination  I 
found  traces  of  the  former  inflammation  of  the  vulva  and  vagina. 
The  meatus  urinarius  was  everted  and  surrounded  by  a  number  of 
papillary  projections,  of  a  deep-red  color,  and  altogether  presenting 
an  appearance  resembling  that  which  is  known  as  vascular  tumor, 
or  carbuncle  of  the  meatus.     See  Fig.  282,  Plate  lY. 

The  diagnosis  then  made  was  subacute  vaginitis,  perhaps  of  gon- 
orrhoeal  origin,  and  inflamed  papilloma  of  the  meatus  urinariuSc 
The  vaginitis  was  treated  in  the  usual  way,  and  soon  terminated 
in  complete  recovery,  but  the  inflammation  and  tenderness  of  the 
meatus  remained  unchanged,  and  annoyed  the  patient  exceedingly. 
She  could  not  walk  or  sit  without  pain,  and  coitus  had  to  be  avoided 
entirely. 

I  presumed  at  first  that  the  disease  of  the  meatus  was  kept  up 
by  the  irritating  discharge  from  the  vagina,  and  I  hoped  that  when 
the  one  was  removed  the  other  would  get  well,  but  such  was  not  the 
case.  I  then  thoroughly  cauterized  the  elevated  and  tender  points 
about  the  meatus  with  nitrate  of  silver.  This  caused  very  great 
pain  at  the  time,  and  was  followed  by  no  improvement.  Pure  nitric 
acid  was  used  in  the  same  way,  but  with  no  better  result  except  to 
destroy  elevations  of  the  mucous  membrane  around  the  orifice.  The 
same  areola  of  inflammation  around  the  meatus  continued,  and  the 
symptoms  remained  the  same.  A  full  account  of  the  progress  of 
the  case  would  be  tedious  and  useless.  Sufiice  it  to  say  that  for 
eight  months  I  treated  the  disease  with  diligence  and  care,  but  at 
the  end  of  that  time  she  was  very  little  better. 

Caustics  and  cauteries  being  unsatisfactory,  I  tried  sedatives  and 
alteratives,  including  iodoform,  iodine,  mercury,  and  bismuth.     At 


DISEASES  OF  THE   GLANDS   OF  THE  FEMALE  URETHRA.     947 

times  the  inflammation  subsided  slightly,  and  the  elevated  points 
became  smaller,  but  in  a  short  time  fresh  proliferations  sprang 
up  and  the  muco-purulent  secretion  continued  to  bathe  the  parts. 
Toward  the  end  of  this  long  period  of  treatment,  and  while  making 
a  critical  examination,  I  observed  that  on  each  side  of  the  meatus 
there  were  two  depressions  tilled  with  a  yellowish  gray  matter,  look- 
ing like  minute  ulcers,  but  upon  probing  them,  wdth  a  view  to  deter- 
mine their  depth,  I  found  that  they  admitted  the  probe  over  half  an 
inch.  After  withdrawing  the  probe,  I  made  pressure  ujDon  the  ure- 
thra from  above  downward,  and  succeeded  in  expressing  a  purulent 
fluid,  which  could  be  distinctly  seen  escaping  from  their  orifices. 
Treatment  was  then  directed  to  these  canals ;  tirst,  they  were  in- 
jected with  tincture  of  iodine,  and  subsequently  they  were  cauter- 
ized by  passing  a  probe  coated  with  nitrate  of  silver  along  their  en- 
tire depth.  Prompt  improvement  followed  this  application.  The 
inflammation  around  the  meatus  gradually  subsided,  and  the  pain 
and  tenderness  passed  away.  In  less  than  two  months  from  the  time 
that  a  correct  diagnosis  was  made  and  appropriate  treatment  em- 
ployed the  patient  recovered  completely.  The  satisfaction  which 
this  gave  to  both  patient  and  physician  will  be  appreciated  when  the 
fact  is  recalled  that  she  had  been  suffering  for  twenty -one  months, 
and  that  for  nine  months  she  had  been  under  my  treatment  without 
any  marked  improvement. 

Such  was  my  experience  with  this  disease  before  I  knew  any- 
thing about  the  presence  and  character  of  the  structures  involved. 
Since  then  I  have  seen  several  cases  of  the  same  kind,  and  have 
found  the  diagnosis  easy  and  the  treatment  satisfactory.  A  brief 
history  of  another  case  will  contrast  agreeably  with  the  former  one  : 

A  delicate  nervous  lady,  aged  thirty-three  years,  married  seven 
years  without  having  had  children.  She  had  suffered  for  one  year 
from  symptoms  resembling  those  of  the  case  given  above.  At  first 
her  sufferings  were  not  so  severe,  but  in  time  they  became  intoler- 
able, and  she  was  compelled  to  consult  her  physician,  who  exam- 
ined her,  and  found  what  lie  supposed  to  be  a  vascular  tumor  of  the 
meatus  urinarius.  He  sent  her  to  me  to  have  it  removed,  I  found 
that  she  had  the  disease  now  under  consideration,  and  a  subacute 
vaginitis  limited  mostly  to  the  upper  and  posterior  portion  of  the  va- 
gina. The  inflamed  papillae  around  the  mouths  of  the  ducts  were 
deep  red,  and  so  tender  as  to  render  it  very  diflScult  to  examine  her. 
She  was  directed  to  use  a  vaginal  douche  of  borax  and  warm  water. 
The  inflamed  papillae  were  touched  with  equal  parts  of  tincture  of 
iodine  and  carbolic  acid,  and  the  ducts  were  injected  with  a  solu- 


948  DISEASES   OF   WOMEN. 

tion  of  3  ii  of  nitrate  of  silver  to  3  i  of  water.  Twice  a  week  sub- 
sequently they  were  injected  with  a  solution  of  two  grains  of 
nitrate  of  silver  to  the  ounce  of  water,  and  finally  borax  and  water 
were  used.     Under  that  treatment  she  recovered  in  six  weeks. 

For  injecting  these  ducts,  I  use  a  hypodermic  syringe  with  the 
needle  made  probe  pointed. 

The  history  of  these  two  cases  may  possibly  convey  the  impres- 
sion that  inflammation  of  these  glands  is  easily  cured.  That  is  only 
true  in  some  cases ;  I  have  seen  others  that  were  exceedingly  obsti- 
nate. The  disease  would  subside,  but  not  fully  disappear,  and  as 
soon  as  all  applications  were  suspended  would  return. 

This  has  led  me  to  think  that  other  methods  of  treatment  may 
yet  be  discovered,  and  has  induced  me  to  lay  open  the  ducts  of 
these  glands  in  the  way  already  described. 

Tuberculosis  of  the  Urethral  Glands. — The  first  case  of  this  kind 
which  I  remember  having  seen  came  under  the  care  of  Prof.  E.  N. 
Chapman  at  the  Long  Island  College  Hospital  while  I  was  his  assist- 
ant. She  ])resented  at  her  first  visit  the  history  and  physical  signs 
of  what  was  then  supposed  to  be  caruncle,  which  was  treated  with 
caustics.  Very  little  relief  followed.  She  soon  gave  evidence  of 
cystitis  which  was  also  treated  for  several  months  without  success. 
The  diagnosis  was  inflammation  of  the  bladder.  After  a  time  she 
disappeared,  but  I  subsequently  learned  that  she  died  in  the  City 
Hospital,  of  pulmonary  tuberculosis.  Upon  reflection  I  am  satis- 
fied that  the  primary  disease  was  tuberculosis  of  the  urethral  glands. 

The  next  case  came  under  my  own  care  in  the  Long  Island  Col- 
lege Hospital.  When  first  seen  she  had  papillomatous  excrescences 
at  the  meatus  and  cystitis,  presumed  to  be  non-specitic.  I  was  at 
that  time  unaware  of  the  presence  of  the  urethral  glands,  and  there- 
fore did  not  at  first  suspect  tuberculosis.  Treatment  gave  her  no 
relief,  and  her  sufferings  were  beyond  description.  In  the  hope  of 
curing  her,  I  made  an  artificial  vesico -vaginal  fistula,  which  relieved 
her  very  much,  but  her  general  condition  became  more  and  more  like 
that  of  a  consumptive.  She  died,  and  a  post-mortem  examination 
revealed  complete  destruction  of  the  left  kidney  from  tuberculosis. 
The  bladder  and  urethra  were  covered  throughout  with  tubercular 
ulcerations.  Since  I  discovered  the  urethral  glands  I  have  seen  two 
cases  of  tuberculosis  affecting  them.  The  history  of  one  of  them 
is  as  follows  : 

A  young  single  lady  first  consulted  me  for  dysmenorrhoea  and 
frequent  and  painful  urination.  I  found  by  examination  that  she 
had   anteflexion  of  the   uterus  and  inflammation  of   the  urethral 


i 


DISEASES  OF   THE   GLANDS  OF   THE   FEMALE  URETHRA.     949 

glands.  The  painful  menstruation  was  partially  relieved  by  correct 
ing  the  flexion.  The  inflamed  glands  were  treated  in  the  manner 
to  be  hereafter  described,  and  the  inflammation  at  that  point  disap- 
peared. Her  frequent  urination  did  not  subside,  however ;  on  the 
contrary,  she  developed  a  marked  cystitis,  which  did  not  yield  to 
treatment.  Her  lungs  at  the  same  time  gave  evidence  of  tubercu- 
losis, which  proved  fatal. 

Recurring  Gonorrhoea  from  Gonorrhceal  InflammatioK.  of  the  Ure- 
thral Glands. — Dr.  H.  C.  Howard,  of  Campaign,  Illinois,  has  re- 
cently had  a  series  of  cases  in  which  gonorrhoea  had  been  communi- 
cated by  the  husband  to  the  wife,  and  cured  in  both,  but  repeatedly 
returned  in  the  case  of  the  husband,  although  he  had  not  been  im- 
properly exposed.  Careful  examination  of  the  wife  showed  that 
the  disease  had  persisted  in  the  little  glands  of  the  female  urethra, 
flrst  described  by  Dr.  A,  J.  C.  Skene,  of  Brooklyn  ("American 
Journal  of  Obstetrics,"  April,  1880),  and  fully  noticed  editorially  in 
the  "  Chicago  Medical  Gazette,"  May  5,  1880.  Dr.  Howard,  be- 
lieving that  these  little  glands  were  continuing  to  pour  out  true 
gonorrhoeal  pus,  although  the  patient  presented  no  other  evidence 
of  the  disease,  and  that  this  pus  had  produced  recurrent  gonorrhcea 
in  the  male,  directed  his  treatment  to  them,  which  consisted  in  the 
application  of  carbolic-acid  crystals.  In  each  case  the  discharge 
disappeared  permanently  under  this  treatment,  and  the  disease  in 
the  male  now  having  been  cured,  did  not  return.  Dr.  Skene  in  his 
original  paper,  expresses  the  opinion  that  in  the  case  which  he  had 
observed,  the  inflammation  was  caused  by  gonorrhoea,  which  per- 
sisted in  the  glands  long  after  the  original  trace  of  the  disease  had 
disappeared.  Dr.  Howard  seems  to  have  been  the  first  to  note  this 
condition  as  a  cause  of  gonorrhoea  recurring  as  often  as  cured  in  the 
male.  His  observation  is  important  as  showing  that  the  female  may 
communicate  the  disease  long  after  it  would  previously  have  been 
pronounced  cured. —  Chicago  Medical  Review,  August  5, 

After  reading  the  account  of  Dr.  Howard's  cases  I  gave  atten- 
tion to  the  subject  and  found  cases  to  correspond  with  his. 

The  following  is  a  fair  example  and  has  additional  value  because 
confirmed  by  another  observer. 

A  widow  who  had  children  and  was  perfectly  well,  contracted 
a  gonorrhoea  which  was  supposed  to  be  cured.  She  married  again 
and  her  husband  developed  a  gonorrhoea  which  he  supposed  was 
a  recurrence  of  the  disease,  having  had  it  before.  He  was  led  to 
this  conclusion  because  his  wife  had  no  evidence  of  being  simi- 
larly affected.     He  was  treated  by  Prof.  Charles  Jewett  and  soon 


950  DISEASES  OF  WOMEN, 

recovered,  but  again  and  again  the  disease  returned.  Dr.  Jewett 
suspected  that  his  wife  might  have  gonorrhea  without  the  usual 
acute  symptoms.  He  sent  her  to  me  for  examination.  I  could  not 
find  the  slightest  evidence  of  any  disease  of  the  urethra,  vagina,  or 
uterus,  but  I  noticed  that  the  orifices  of  the  urethral  glands  were 
rather  deeper  in  color  than  normal.  To  make  sure  I  laid  the  ducts 
open,  and  found  pus  in  both  of  them.  They  were  thoroughly  cau- 
terized with  carbolic  acid  and  tincture  of  iodine.  From  that  day 
till  the  present  time,  now  four  years,  there  has  been  no  further  evi- 
dence of  gonorrhoea  in  that  family. 


CHAPTER  LII. 

VESICAL    AND   URETHRAL    FISTULJE. 

Classification  and  Pathology.  —  The  classification  of  fistulse 
which  I  shall  adopt  is  as  follows : 

I.  Vesico- Vaginal. — This  is  subdivided  into  (a)  those  occurring 
in  the  trigone,  the  opening  being  situated  at  the  neck  of  the  blad- 
der ;  ih)  those  occurring  at  the  bas-fond,  the  opening  involving  the 
inferior  portion  of  the  bladder. 

II.  Urethro-Yaginal. — The  opening  being  between  the  urethra 
and  vagina. 

III.  Utero-Yaginal. — The  opening  communicating  with  the 
bladder,  vagina,  and  cervix,  or  with  the  body  of  the  uterus. 

lY.  In  this  variety  the  entire  vesico-vaginal  wall  is  destroyed, 
and  sometimes  the  urethro-vaginal  wall  also.  This  variety  is  for- 
tunately quite  rare. 

The  relative  frequency  of  these  varieties  is  about  in  the  order  in 
which  they  are  given  in  the  classification.  The  last  and  rarest  one 
is  attended  with  extensive  destruction  of  tissue,  and  includes  the  first 
three  classes.  In  fact,  it  covers  the  ground  occupied  by  all  the  other 
varieties. 

The  direction  of  these  fistulas  may  be  transverse,  oblique,  or 
longitudinal,  and  their  form  may  be  oval,  round,  linear,  angular,  or 
irregular.  The  dimensions  of  the  opening  also  vary  from  one  so 
small  as  barely  to  admit  an  ordinary  probe  to  one  measuring  two 
inches  in  diameter.  The  direction  of  the  fistula  may  possibly  be 
determined  by  the  cause  of  the  primary  injury. 

The  form  of  the  opening  depends  upon  the  arrangement  of  the 
muscular  fibers  of  the  vagina.  This  influences  the  line  of  laceration, 
and  also  the  healing  process,  which  latter  modifies  the  final  shape  of 
the  opening. 

The  condition  of  the  borders  of  the  fistulas  and  their  form  differ 
much  at  first;  sometimes  they  are  thin,  inverted,  quite  pale,  and 

951 


952  DISEASES  OF   WOMEN. 

smooth ;  this  is  especially  the  case  with  the  upper  border.  In  other 
instances  they  are  thick,  soft,  and  muscular,  or,  again,  they  may  be 
hard,  inelastic,  and  anaemic.  The  mucous  membrane  of  the  bladder 
often  projects  through  the  opening  if  it  is  large,  forming  a  red  erect- 
ile tumor. 

Symptomatology. — The  chief  symj^tom  is  incontinence  of  urine. 
This  is  always  the  same,  no  matter  how  small  or  how  large  the  open- 
ing may  be.  In  some  cases,  indeed,  this  is  the  only  symptom.  In 
others  there  is  much  pain  in  the  pelvic  region,  and  irritation  from 
the  constant  flow  of  urine,  the  pelvic  pain  being  most  marked  at 
first,  and  in  those  cases  in  which  there  is  much  scar  tissue. 

Sometimes  there  is  inflammation  of  the  bladder  and  urethra, 
which  causes  pain. 

If  the  fistula  is  due  to  23arturition,  the  state  of  the  bladder  im- 
mediately succeeding  the  labor  is  such  that  for  two  or  three  days 
there  is  an  inability  to  evacuate  its  contents  without  some  pain  or 
uneasiness,  requiring  perhaps  the  use  of  the  catheter.  After  this 
the  urine  may  escape  through  the  urethra,  or  it  may  do  so  from  the 
very  beginning. 

In  from  five  to  ten  days  after  confinement  the  urine  begins  to 
escape  entirely  from  the  vagina.  A  sense  of  something  giving  way 
is  sometimes  felt  at  that  time. 

The  labia,  the  inner  surface  of  the  thighs,  and  the  perinseum, 
being  constantly  bathed  in  the  urine,  become  red,  inflamed,  and  cov- 
ered with  pustules,  which  sometimes  form  ulcers  of  considerable 
depth.  The  external  genitalia  and  the  surface  of  the  vagina  fre- 
quently become  incrusted  with  a  saline  deposit  consisting  of  urates, 
and  there  is  also  a  strong  urinous  odor  about  the  person  and  the 
clothing  of  the  patient. 

These  symptoms  and  physical  signs,  while  they  are  strong  evi- 
dences of  fistula,  are  not  sufficient  to  base  a  diagnosis  upon.  A  physi- 
cal exploration  of  the  parts  must  be  made  to  ascertain  with  certainty 
the  presence  or  absence  of  a  fistula. 

Physical  Signs. — The  patient  should  be  placed  upon  a  table  in 
Sims's  position  in  a  good  light,  Sims's  speculum  should  be  used  to 
open  the  vagina,  and  the  perinseum  should  be  drawn  well  back 
toward  the  sacrum  until  the  entrance  of  the  air  distends  the  vaginal 
cavity. 

The  fistula,  if  one  exists,  will  most  likely  be  at  once  detected, 
unless  it  is  very  small.  If  it  is  not  found  in  this  way,  a  probe  should 
be  used  to  explore  any  pockets  or  depressions  that  may  exist  in  the 
vaginal  wall.     Should  this  fail,  milk  may  be  injected  through  the 


VESICAL   AND  URETHRAL  FISTULA.  953 

urethra  into  the  bladder  to  distend  its  walls,  and  special  attention 
given  to  see  if  any  of  it  passes  into  the  vagina. 

Incontinence  from  some  muscular  lesion  of  the  neck  of  the  blad- 
der, which  allows  the  urine  to  find  its  way  back  into  the  vagina  after 
escaping  passively  from  the  urethra,  is  the  only  affection  which 
simulates  fistula,  but  a  careful  examination  made  in  the  manner  just 
described  will  determine  the  diagnosis. 

Complications. — These  are  stricture  of  the  vagina,  recto- vaginal 
fistula,  obliteration  of  the  urethra,  and  cicatrices  of  the  vagina  and 
cervix  uteri.  Inflammation  of  the  edges  of  the  fistula  and  deposits 
of  urinary  salts  in  the  vagina  may  be  present ;  cystitis,  vaginitis,  and 
m°ethritis  may  also  be  found  accompanying  the  fistulse. 

Prognosis. — If  the  fistula  is  of  such  a  nature  that  it  can  be 
closed  by  an  operation  with  any  reasonable  hope  of  success,  and  in 
the  great  majority  of  cases  this  is  possible,  the  chances  of  a  perfect 
recovery  are  excellent. 

Good  operating  will  generally  insure  success,  except  in  extraor- 
dinary cases,  and  these  are  very  rare. 

Causation. — Pressure  of  the  foetal  head  is  the  most  common 
cause  of  vesico-vaginal  fistula.  Almost  all  authors  agree  in  attribut- 
ing about  ninety  per  cent  to  this  cause. 

Compression  of  the  soft  parts  in  tedious  labor  causes  death  and 
sloughing  of  these  tissues,  and  the  edges  of  the  opening  thus  made 
failing  to  unite,  the  fistulous  opening  results.  If  the  vitality  of  the 
parts  is  not  completely  destroyed,  but  is  greatly  diminished,  inflam- 
mation and  ulceration  may  occur,  and  lead  to  the  same  result  as  in 
the  case  of  sloughing.  The  best  evidence  that  pressure  of  the  foetal 
head  in  delayed  labor  is  the  chief  cause  of  fistula  is  obtained  from 
the  fact  that  since  the  progress  and  improvement  in  the  obstetric 
art,  by  which  difficult  labors  are  more  promptly  terminated,  fistula 
is  far  less  frequent  than  formerly. 

Wounds  of  the  vesico-vaginal  wall  may  occur  during  the  use  of 
instruments  or  long-continued  efi:orts  in  manual  delivery.  The  slip- 
ping of  a  perforator  in  cases  of  craniotomy  may  be  especially  men- 
tioned as  likely  to  open  the  vesico-vaginal  septum. 

The  forceps  have  come  in  for  a  large  share  of  blame  in  times 
past,  but  they  have  little  agency  in  producing  such  an  accident ;  the 
earlier  and  the  more  frequent  that  they  are  employed  by  educated 
hands,  the  fewer  fistulse  will  occur.  This  is  a  fact  obtained  from 
the  records  of  obstetrics  and  gynecology. 

Foreign  substances  in  the  bladder — vesical  calculi,  for  example 
—may  cause  fistula  by  perforating  the  vesico-vaginal  septum.    Many 


954  DISEASES  OF   WOMEN. 

years  ago  I  saw  a  case,  with  Dr.  J.  H.  Hobart  Burge,  of  Brooklyn, 
in  which  this  happened.  The  fii'st  calculus  formed  in  the  bladder 
was  discharged  through  the  vesico- vaginal  septum,  and  several  more 
were  discharged  through  the  fistula.  Badly  fitting  pessaries,  worn 
for  too  great  a  length  of  time,  may  also  be  mentioned  among  the 
causes  inducing  this  lesion.  Then  there  are  a  number  of  cases  re- 
corded in  which  a  pessary  has  destroyed  the  vesico- vaginal  septum. 
The  process  by  which  the  opening  is  made  is  no  doubt  ulceration 
from  pressure  and  irritation.  The  process  of  ulceration  is  probably 
favored  by  the  deposit  on  the  instrument  of  the  salts  of  the  urine, 
and  the  irregularities  of  this  deposit  produce  destruction  of  tissue. 
There  is  no  doubt  that  this  accident  happened  more  frequently  in 
past  times  when  the  material  used  for  pessaries  was  unsuitable,  and 
the  methods  of  adapting  them  were  not  so  well  understood  as  they 
are  now. 

The  vesico-vaginal  septum  is  often  destroyed  by  malignant  dis- 
ease in  the  advanced  stages,  but  this  does  not  belong  to  the  subject 
on  hand,  and  ^vill  not  be  discussed  here. 

Treatment. — The  treatment  of  fistula  is  either  palliative  or  cura- 
tive by  surgical  means. 

Palliative  treatment  is  little  more  than  an  attempt  to  make  the 
patient  comfortable  by  protecting  her  from  irritation  and  filth  con- 
sequent upon  the  constant  flow  of  urine. 

The  curative  treatment  includes  the  jireparation  of  the  patient, 
the  operation,  and  the  subsequent  management. 

Preparatory  Treatment. — The  operation  for  the  cure  of  fistula 
should  not  be  done  until  after  the  lapse  of  at  least  three  months 
from  the  date  of  its  occurrence.  Some  have  operated  earlier  with 
success,  but  these  early  operations  can  not  be  expected  to  result  suc- 
cessfully. It  requires  at  least  three  months  before  the  system  has 
completely  recovered  from  the  influence  of  gestation  and  parturi- 
tion, and  complete  involution  of  tlie  sexual  organs  is  secured. 

In  case  of  fistula  the  process  of  involution  is  apt  to  be  delayed 
from  the  local  irritation  and  general  depression  which  usually  attend 
such  injuries.  If  the  patient  is  feeble,  with  loss  of  appetite,  and  is 
nervous,  months  of  preparatory  treatment  may  be  necessary,  con- 
sisting of  good  diet,  fresh  air,  attention  to  the  intestinal  and  other 
secretions,  with  the  use  of  tonics. 

It  is  certain  that  no  one  familiar  with  the  treatment  of  this  form 
of  fistula  will  be  rash  enough  to  subject  his  patient  to  the  incon- 
venience of  such  an  operation  before  attending  to  these  preliminary 
measures.     There  is  no  operation  in  surgery  which   depends  more 


VESICAL  AND   URETHRAL  FISTULA.  955 

for  its  success  on  good  general  health  than  this  one.  As  regards  the 
local  treatment,  all  inflammation  must  have  subsided,  and  good  gen- 
eral nutrition  of  the  tissues  about  the  fistula  sliould  be  secured  in 
order  to  give  a  fair  chance  to  obtain  union  after  the  operation.  To 
secure  all  this,  due  attention  to  cleanliness  should  be  given  and  the 
vaginal  douche  of  hot  water  frequently  employed.  The  excoriation 
due  to  the  urine  flowing  over  the  parts  can  be  relieved  by  Lister's 
ointment  of  boracic  acid.  The  saline  incrustations  which  form  on 
the  edges  of  the  fistula  and  other  parts  can  be  removed  with  the 
forceps,  and  their  reformation  can  be  checked  by  tonics,  the  min- 
eral acids  being  specially  indicated. 

About  one  week  after  menstruation  has  ceased  is  the  best  period 
to  operate.  If  it  is  delayed  until  near  a  menstrual  period  the  anses- 
thetic  which  must  be  given  and  the  irritation  produced  by  the  oper- 
ation itself  are  liable  to  induce  premature  menstruation.  Besides, 
the  tissues  are  in  the  best  condition  to  undergo  the  healing  process 
at  that  time. 

The  complication  most  commonly  met  with  is  stricture  of  the 
vagina  and  scar  tissue  at  the  edges  of  the  fistula.  No  operation 
should  be  undertaken  until  these  are  disposed  of  as  far  as  possible. 
The  methods  of  relieving  stricture  of  the  vagina,  and  also  of  treat- 
ing scar  tissue,  are  by  dividing  the  cicatricial  bands  and  dilating. 

For  a  fuller  discussion  of  this  subject  the  reader  is  referred  to 
the  section  of  this  work  on  cicatrices  of  the  cervix  uteri  and  vagina. 

It  may  be  remarked  that  in  cases  where  the  scar  tissue  can  not 
be  removed  entirely,  the  best  results  are  obtained  by  dilatation  with 
the  tampon. 

OPERATION    FOR   THE    CURE    OF    FISTULiE. 

An  exceedingly  interesting  chapter  might  be  written  on  the 
many  methods  suggested  and  practiced  to  close  vesico-vaginal  fistula 
but,  while  interesting,  it  would  not  be  sufliciently  profitable  to  oc- 
cupy time  in  this  connection.  It  may  be  briefly,  yet  comprehen- 
sively, stated  that  all  operations  and  all  methods  of  treatment  tried 
were  failures  until  Dr.  J.  Marion  Sims  by  his  genius  solved  the 
problem.  Furthermore,  it  may  be  stated  that  all  modifications  of 
Sims's  method  suggested  and  practiced  by  others  have  not  been  im- 
provements worthy  of  notice.  A  very  few  changes  of  a  trivial 
character  have  been  made  which  simplify  some  of  the  details  of  the 
operation,  but  beyond  this  the  operation  in  principle  and  practice 
remains  the  same  as  when  given  to  the  profession  by  Dr.  Sims,  to 


956  DISEASES  OF  WOMEN. 

whom  the  world  is  indebted  for  this  grand  triumph  of  surgical 
science  and  art.  In  describing  the  operation  I  shall  first  give  Sims's 
method  as  closely  as  I  can,  and  then  note  such  slight  changes  as 
have  been  made  by  other  operators.  I  will  be  permitted  to  state  here 
that  before  undertaking  this  important  operation  the  surgeon  should 
have  acquired  facility  in  the  practice  of  Sims's  methods  of  operating 
upon  the  cervix  uteri  and  vagina.  The  placing  of  the  patient  in  the 
proper  position,  the  management  of  Sims's  speculum  when  held  by 
an  assistant,  and  the  use  of  gynecological  instruments  should  all  be 
familiar  to  the  operator.  The  success  of  the  operation  involves  so 
much  to  the  patient,  that  all  reasonable  efforts  should  be  made  to  se- 
cure success,  and  perfect  operating  is  the  first  essential  to  that  success. 

The  treatment  is  divided  into  four  parts  :  first,  the  placing  the 
patient  in  the  proper  position  and  in  a  good  light ;  second,  the  par- 
ing the  edges  of  the  tistula;  third,  the  introduction  of  the  sutures 
and  tying  them  ;  and  fourth,  the  after  management.  The  first  pro- 
cedure is  presumed  to  be  familiar  to  the  reader,  but  if  not,  refer- 
ence should  be  made  to  the  chapter  in  which  a  detailed  account  of 
Sims's  position  is  given  and  also  the  management  of  Sims's  speculum. 
The  operation  is  naturally  divided  into  two  parts — first,  paring  the 
edges  of  the  fistula,  second,  passing  the  sutures  and  tying  them. 

The  patient  having  been  placed  in  Sims's  position  upon  the  oper- 
ating table,  and  Sims's  speculum  having  been  introduced,  one  assistant 
holds  the  speculum  while  another  does  the  sponging  and  assists  with 
the  instruments  and  sutures.  A  thoroughly  competent  physician 
should  be  secured  to  give  the  anaesthetic.  Very  much  depends 
upon  the  patient  being  kept  perfectly  quiet,  and  still  free  from  the 
dangers  of  a  too  profound  anaesthesia. 

Paring  the  Edges  of  the  Fistula. — The  lower  edge  of  the  fistula  is 
seized  with  a  Sims's  tenaculuni  (Fig.  283),  or  a  tissue  forceps  (Fig. 

74),  according  to  the 
preference  of  the  op- 
.     ,  ,  erator.     Then  with  a 

Fig.  283. — Sims  s  tenaculum.  . 

curved  scissors  (r  ig. 
75)  a  strip  is  removed  all  around  the  fistula,  extending  from  the 
mucous  membrane  of  the  bladder  out  upon  the  vaginal  membrane  at 
least  three  eighths  of  an  inch  (Fig.  2S4).  Care  should  be  taken  not 
to  wound  the  mucous  membrane  of  the  bladder.  It  is  better  to 
keep  unbroken  the  piece  that  is  removed,  if  possible.  If  upon  care- 
ful inspection  there  is  any  portion  of  the  vivified  surface  that  is 
not  completely  and  uniformly  pared,  it  should  be  trimmed  until  a 
perfectly  smooth  and  beveled  surface  is  obtained.     Fig.  28'1  shows 


VESICAL  AND  URETHRAL   FISTULA. 


95Y 


the  beveling  of  the  vivified  edges  of  the  fistula.     The  paring  should 
be  done  with  a  view  also  of  making  the  edges  of  the  fistula,   when 


Fig. 


Operation  for  vesico-vaginal  fistula :   paring  the  edges. 


brought  together,  form  a  straight  or  slightly  curved  line.  The 
direction  of  the  line  of  coaptation  will  of  necessity  depend  upon 
the  size  and  long  diameter  of  the  fistula.  "When  it  is  possible,  I 
prefer  to  make  this  line  correspond  with  the  long  diameter  of  the 
vagina,  but  in  case  the  long  diameter  of  the  fistula  is  at  right  an- 
gles to  the  axis  of  the  vagina,  the  edges  must  be  brought  together 
in  that  position.  While  the  surgeon  is  paring  the  edges  the  assist- 
ant sponges  the  wound  with  sponges  held  in  Sims's  long-handled 
sponge-holders  (Fig.  285). 


Fig  285. — Sims's  sponge-holder. 

When  the  scissors  are  used  to  do  the  paring  there  is  not  much 
hiaemorrhage.  Occasionally  there  is  troublesome  bleeding  which  re- 
quires to  be  arrested  by  hot  water  either  injected  or  applied  with 
sponges.  This  will  arrest  all  troublesome  oozing,  and  if  any  vessel 
is  found  that  persists  in  bleeding  it  can  be  closed  by  passing  a  cat- 
gut or  silk  suture  under  it  from  the  vaginal  surface  some  distance 
from  the  vivified  edge. 

Introduction  of  the  Sutures. — Dr.  Sims  employed  silver-wire  sut- 
ures in  this  operation,  and  by  this  he  secured  one  great  element  of 
success.     At  the  time  that  he  introduced  this  metallic  sutm-e  it  was 


958 


DISEASES  OF  WOMEN. 


Fig.  286. — Emmet's  needles. 


the  only  one  that  was  aseptic  and  without  irritating  qualities,  both 
of  which  were  absolutely  necessary  to  secure  union  in  the  operation. 
Since  that  time  a  better  knowledge  of  all  that  pertains  to  aseptic  and 
antiseptic  surgery  has  made  it  practicable  to  render  silk  as  reliable 
as  the  silver  wire.  I  have  fully  discussed  this  subject  in  the  preced- 
ing  pages,  so  that  I  need  only  say  here  that  I  use  the  silk  in  this 
operation.  Long  before  I  had  given  up  silver-wire  sutures,  Simon, 
of  Germany,  had  employed  silk  in  operating  for  vesico-vaginal  fistula, 
and  with  success.  This  fact,  and  my  own  experience,  which  has 
been  just  as  favorable  as  when  I  used  wire  sutures,  lead  me  to  be- 
lieve that  silk  will  be  the  suture  of  the  future,  and  hence  I  will  dis- 
cuss the  exclusive  use  of  it  in  this  operation.  That  the  silk  is  as 
successful  as  silver  wire  I  have  proved  to  my  own  satisfaction  in  many 
cases,  and  it  is  much  more  easily  managed  both  in  the  introduction, 
tying,  and  removal. 
No.  5  braided  silk,  or 
No.  3,  if  the  walls  of 
the  septum  are  thin, 
prepared  as  heretofore 
directed,  is  used  with 
Emmet's  needle.  The 
length  of  the  needle  varies  according  to  the  thickness  of  the  tis- 
sues to  be  sutured  and  the  fancy  of  the  operator.  The  needle  is 
grasped  in  the  forceps  (Fig.  82)  so  that  the  two  are  at  right  an- 
gles, if  the  line  of  coaptation  is  parallel  to  the  axis  of  the  vagina, 
but  if  the  line  runs  across  the  vagina,  the  needle  and  forceps  are 
arranged  in  a  line.     The  tissues  are  held  with  a  tenaculum,  and  the 

first  suture  is  introduced  at  the 
angle  farthest  from  the  operator. 
The  needle  is  carried  through  one 
side,  and  when  its  point  emerges 
it  is  caught  with  Emmet's  coun- 
ter-pressure instrument  (Fig.  119). 
The  first  suture  is  then  held  by  the 
assistant  who  holds  the  speculum, 
and  this  fixes  the  edges  so  that  the 
other  sutures  can  be  passed  with 
more  facility.  Fig.  288  shows  the 
first  sutures  tied,  and  the  others  introduced.  The  majority  of  sur- 
geons introduce  the  suture  about  half  an  inch  from  the  incision  on 
the  vaginal  side,  and  at  the  edge  of  the  mucous  membrane  of  the 
bladder.     I  much  prefer  to  pass  the  suture  in  a  curved  line  from 


Fig.  287. — The  curved  track  of  the  needle; 
b,  bladder  surface  ;  v,  vaginal  surface. 


VESICAL  AND  URETHRAL  FISTULA. 


959 


one  edge  to  the  other  of  tlic  vivified  surface  (Fig.  287).     If  I  find 
that  this  does  not  draw  the  surfaces  together  with  facility,  I  pass 


Fig.  2SS. — Operation  for  vesico-vaginal  fistula :  the  sutures  in  place :  method  of  using 
the  counter-pressure  instrument  in  tying  the  sutures. 

half  of  the  sutures  a  quarter  of  an  inch  back  from  the  incised 
surfaces,  and  then  introduce  superficial  sutures  between  them  to 
keep  the  edges  from  curving  inward  when  the  sutures  are  tied. 

The  method  of  introducing  sutures  was 
fully  described  and  illustrated  in  the  chapter 
on  injuries  of  the  pelvic  floor,  but  so  much 
depends  upon  the  accuracy  with  which  this 
is  accomplished  that  I  refer  to  it  again. 

The  great  point  is  to  make  the  needle 
grasp  more  tissue  in  the  central  portion  of 
the  vivified  surface  than  at  the  edges,  so  that 
when  the  suture  is  tightened  the  opposing  surfaces  will  make  two 
straight  lines  in  place  of  two  concaves,  as  would  be  the  case  if  the 
needle  was  passed  straight  through  the  tissues.  One  can  tell  how 
the  sutures  will  tie  by  observing  how  the  free  surface  appears  when 
the  needle  is  in  place.  "When  the  needle  is  introduced  completely, 
the  tissues  resting  upon  the  needle  should  give  a  convex  surface. 

The  number  of  sutures  to  be  used  should  be  sufiicient  to  bring 
the  edges  accurately  together.  This  requires  that  they  should  be 
about  three  sixteenths  of  an  inch  apart,  if  No.  3  silk  is  used.  Hav- 
ing introduced  all  the  sutures,  the  bladder  should  be  thoroughly 
washed  out,  in  order  to  free  it  from  all  blood  that  may  have  accumu- 


FiG.  289. — Two  sutures  tied. 


960  DISEASES   OF  WOMEN. 

lated  in  it.  Special  care  should  be  taken  to  make  sure  that  no  blood- 
clot  is  left  in  the  bladder.  The  sutures  should  then  be  tied  in  the 
same  manner  as  has  already  been  described  in  the  directions  for 
restoring  the  cervix  uteri  after  laceration. 

After  Treatment. — The  after  treatment  is  very  simple  indeed, 
as  I  now  conduct  it.  The  patient  is  placed  in  bed,  and,  if  there  is 
pain  of  a  severe  nature,  opium  is  given  to  relieve  it.  This  is  very 
seldom  necessary,  the  pain  being  very  shght,  as  a  rule.  During  the 
first  twenty-four  hours  the  catheter  is  passed  every  four  or  six  hours, 
and  oftener  if  the  patient  has  a  desire  to  urinate ;  after  that,  she  is 
allowed  to  urinate  when  she  desires  to  do  so.  If  there  is  vomiting 
after  the  anaesthetic,  sips  of  hot  water  are  given.  The  tampon  is 
removed  on  the  second  day,  and  the  bowels  are  moved  by  enema  on 
the  third  day.  I  keep  the  patient  in  bed,  but,  after  the  first  twenty- 
four  hours,  she  is  permitted  to  change  her  jjosition  whenever  that 
is  necessary  to  secure  her  comfort,  but  she  is  not  permitted  to  leave 
the  recumbent  position.  On  the  eighth  day  the  sutures  are  removed, 
and,  if  the  result  is  perfect,  the  patient  is  permitted  to  gradually 
resume  her  usual  duties.  In  some  cases  there  is  a  slight  cystitis,  in- 
dicated by  the  presence  of  mucus  in  the  urine  and  frequent  urina- 
tion. This  should  be  managed  by  washing  the  bladder  as  directed 
under  the  head  of  the  treatment  of  cystitis. 

The  after  treatment  described  above  is  nearly  the  same  as  that 
practiced  by  Simon,  and  I  am  satisfied  that  it  gives  as  good  results 
as  any.  It  has  also  some  great  advantages.  The  patient  escapes  the 
great  discomfort  of  wearing  the  catheter  and  remaining  absolutely 
in  one  position,  as  she  must  do  if  the  catheter  is  retained.  There  is 
also  much  less  danger  of  cystitis  or  calculus  if  the  catheter  is  not 
retained.  Should  any  one  feel  disposed  to  use  the  catheter,  I  may 
say  that  Sims's  new  style,  as  figured  on  page  251  of  Thomas's  work 
on  "  Diseases  of  Women,"  is  the  best  in  general  use.  I  have  also 
employed  a  soft-nibber  catheter,  which  is  very  comfortable.  It  is 
retained  in  the  bladder  by  passing  around  it  a  piece  of  adhesive  plas- 
ter, to  which  silk  threads  are  attached  and  fastened  to  a  strap  carried 
around  the  waist. 

ILLUSTRATIVE   CASES. 

The  Simplest  Form  of  Vesico- Vaginal  Fistula. — In  the  -winter  of 
188f)  my  associate,  Pi-of.  Nilscn,  brought  a  patient  to  my  clinic,  at 
the  New  York  Post-Graduate  School,  who  had  a  bilateral  lacera- 
tion of  the  cervix  uteri  and  a  vesico-vaginal  fistula  a  quarter  of  an 
inch  in  diameter,  located  in  the  median  line  midway  between  the 
neck  of  the  bladder  and  the  cervix  uteri.     These  injuries  resulted 


VESICAL  AND  URETHRAL  FISTULA.  961 

from  her  last  confinement,  wliich  was  a  veiy  tedious  one.  The  tis- 
sues around  the  fistuhi  were  in  a  perfectly  healthy  condition.  A 
tenaculum  was  passed  through  both  edges  of  the  fistula  exactly  in  its 
center,  care  being  taken  not  to  include  the  mucous  membrane  of  the 
bladder  in  the  grasp  of  the  instrument.  Traction  was  then  made 
with  the  tenaculum,  which  raised  a  cone-shaped  projection  in  the 
vagina,  the  fistula  being  in  the  apex  of  the  cone.  While  the  parts 
were  held  in  this  position,  the  edges  were  pared  with  one  clip  of  the 
curved  scissors.  The  piece  of  tissue  removed  was  oblong,  with  the 
fistulous  opening  in  its  center.  The  wound  left  was  more  than  an 
inch  long,  and  nearl}^  three  quarters  of  an  inch  wide  on  the  vaginal 
side,  while  the  opening  in  the  mucous  membrane  of  the  bladder  was 
not  much  larger  than  before.  At  the  upper  and  lower  angles  of 
the  wound,  a  little  more  tissue  in  the  vaginal  wall  was  removed  with 
the  tenaculum  and  scissors,  and  that  completed  the  vivifying.  Seven 
prepared  silk  sutures  were  introduced  and  tied,  the  bladder  being 
first  washed  out,  and  the  operation  was  comj)leted. 

The  lacerated  cervix  was  then  restored  in  the  usual  way.  The 
two  operations  occupied  less  than  an  hour.  The  patient  was  then 
put  to  bed,  and  she  rested  fairly  well  during  the  night.  About  five 
hours  after  the  operation,  which  was  performed  between  eight  and 
nine  o'clock  in  the  evening,  the  patient  expressed  a  desire  to  urinate, 
and  the  nurse  passed  the  catheter.  After  this  the  patient  passed 
urine  about  every  five  hours  for  the  first  three  days  and  nights,  and 
subsequently  at  longer  intervals. 

There  was  no  other  treatment  except  that  the  patient  was  kept 
in  the  recumbent  position.  At  my  next  clinic,  one  week  afterward. 
Prof.  Nilsen  removed  the  sutures  from  the  fistula  and  cervix,  and 
found  the  result  perfect  in  both  operations.  When  the  sutures  were 
removed  there  was  scarcely  a  trace  of  the  point  of  union  where  the 
fistula  had  been. 

Fistula  complicated  with  Laceration  of  the  Anterior  Wall  of  the 
Cervix  Uteri.  {By  T.  A.  Emmet,  M.  D.) — Ann  Murphy,  a  native 
of  Ireland,  aged  forty-one,  was  admitted  to  the  hospital,  October  5, 
1864,  from  the  city. 

In  May,  185Y,  she  had  been  discharged  cured  from  the  hospital 
after  an  operation  by  Dr.  Sims  for  the  relief  of  a  utero-vesico- 
vaginal  fistula  resulting  from  a  laceration  directly  through  the 
anterior  lip  into  the  base  of  the  bladder.  Nine  months  after  her 
discharge,  she  had  a  miscarriage  at  the  third  month,  and  a  year 
afterward  another  at  two  months. 

In  her  second  pregnancy,  at  full  term,  labor  commenced  by  a 
62 


962  DISEASES  OP  WOMEN. 

sudden  rupture  of  the  membranes  on  Tuesday  evening,  December, 
1861.  Until  9  p.  m.  of  the  Thursday  following  the  pains  were 
slight  and  irregular.  Labor  then  came  on  regularly,  and  within  an 
hour  afterward  she  was  delivered  naturally  of  a  still-born  infant,  of 
the  average  size,  with  the  feet  presenting.  The  urine  began  to 
escape  involuntarily  after  delivery.  No  slough  was  passed,  and 
she  recovered  as  from  a  natural  labor. 

Pathological  Condition. — Laceration  had  again  taken  place  along 
the  line  of  the  previous  operation,  through  the  anterior  lip,  directly 
in  the  median  line.  The  fissure  through  the  cervix  had,  however, 
closed  nearly  to  the  uterine  canal,  leaving  a  small  fistula  in  the  base 
of  the  bladder  a  few  lines  in  front  of  the  neck. 

October  5th. — The  opening  being  so  small,  little  more  than  its 
edges  were  denuded,  and  the  raw  surfaces  were  brought  together 
with  three  sutures.  On  removing  these  an  opening  of  about  the 
same  size  was  found  near  the  cervix,  leading  forward  into  the  fistula. 
In  closing  the  fistula,  a  portion  of  the  vaginal  surface  around  the 
opening  had  been  scarified,  as  well  as  its  edges,  for  the  purpose  of 
increasing  the  breadth  of  surface  brought  together.  As  the  opera- 
tion was  so  simple,  either  care  had  not  been  taken  to  pass  a  sufli- 
cient  number  of  sutures  to  obliterate  entirely  the  fold  formed  just 
in  front  of  the  cervix,  on  doubling  the  surfaces  together,  or  else  the 
sutures  at  this  point  had  been  twisted  too  tight,  so  as  to  cut  out  from 
below  upward. 

October  30th. — For  some  distance  around  the  opening  the  tissue 
was  excavated  with  a  pair  of  scissors,  so  that  the  surface  was  made 
to  slope  inward  to  the  opening  of  the  fistula  in  the  bladder.  The 
rest  of  the  fistulous  edge  was  then  removed,  as  well  as  a  portion 
of  the  cervix,  and  the  old  cicatricial  tissue  was  got  rid  of  by  this 
means.  But  before  these  surfaces  could  be  brouo;ht  together,  it  was 
necessary  to  make  an  incision  on  each  side  to  relieve  the  tension 
which  would  otherwise  have  existed.  "When  the  surfaces  were  folded 
together,  the  line  of  union  extended  to  such  a  distance  beyond  each 
extremity  of  the  fistula  that  the  fold  thus  formed  was  lost  in  the 
neighboring  tissue.  Nine  sutures  were  used.  The  patient  Avas  dis- 
charged cured  November  18,  1864. 

It  is  frequently  more  difiicult  to  close  a  small  fistula  than  to  close 
one  where  a  large  portion  of  the  base  has  been  lost.  On  account  of 
its  size,  the  temptation  is  always  great  to  remove  simply  the  edges 
of  the  opening,  instead  of  extending  the  scarification  in  the  pro- 
posed line  of  union  in  the  form  of  a  long  oval,  so  as  to  obviate  the 
formation  of  the  fold  at  each  end. 


VESICAL  AND  URETHRAL  FISTULiE.  963 

This  woman,  about  a  year  after  her  discharge,  gave  birth  by  a 
natural  lal)or  to  her  hrst  living  child.  Some  eighteen  months  sub- 
sequent to  the  operation  she  came  with  her  child  to  see  me.  I 
made  an  examination  for  the  purpose  of  ascertaining  whether  lacer- 
ation of  the  anterior  lip  had  again  occurred,  and  was  pleased  to  find 
that  the  line  of  union  was  perfect.  On  passing  a  sound  into  the 
uterine  canal,  I  was  surprised  to  find  a  suture,  Avhich,  from  its 
length,  I  was  unable  to  remove  until  it  had  been  bent  upon  itself. 
It  proved  to  be  the  one  which  had  been  passed  nearest  the  os,  and 
which  by  some  means  had  been  turned  over  backward  into  the  canal, 
with  its  end  in  the  direction  of  the  fundus.  The  portion  nearest  to 
the  fistula  had  become  buried  in  the  cervix,  with  over  half  an  inch 
of  the  other  end  free  in  the  uterine  canal.  She  had  given  birth  to 
her  child,  and  the  suture  had  remained  for  over  eighteen  months 
without  its  presence  causing  her  any  trouble.  It  has  occurred  to 
me  that  the  remaining  of  this  suture,  which  was  passed  deep  through 
the  neck  on  a  line  with  the  vaginal  junction,  may  have  been  a  for- 
tunate circumstance  in  preventing  a  recurrence  of  the  laceration. 

URETHRAL    FI3TULA. 

Dr.  Emmet  has  had  the  largest  experience  with  this  form  of 
fistula,  and  has  been,  of  all  the  surgeons  I  know,  the  most  success- 
ful in  its  management.  I  regard  him  as  the  highest  authority  on 
this  subject. 

The  only  fistulse  of  the  urethra  that  I  have  seen  have  been  those 
made  by  myself  and  others  by  urethrotomy.  In  my  own  cases  the 
fistulas  were  made  for  the  relief  of  dilatation  of  the  middle  third  of 
the  urethra  accompanied  by  ulceration.  The  others  were  made  for 
various  purposes — one  for  the  cure  of  cystitis,  one  for  the  purpose 
of  making  a  diagnosis,  and  so  on.  At  least  this  is  according  to  the 
information  received,  taking  the  clinical  history  given  in  the  litera- 
ture of  the  subject.  There  is  nothing  in  the  jDathology  or  method 
of  treatment  of  fistula  in  this  location  that  difiers  from  that  of  vesico- 
vaginal fistula.  It  is,  however,  very  much  less  troublesome,  there 
being  no  incontinence  of  urine  unless  the  fistula  involves  the  neck 
of  the  bladder,  the  operation  for  closing  the  urethral  fistula  being 
the  same  as  in  the  vaginal  fistula. 

There  is  no  need  of  anything  more  being  said  on  this  subject. 
Cases  of  urethral  fistula  such  as  I  have  referred  to  would  add  noth- 
ing of  value ;  hence  I  shall  give  the  history  of  the  following  case, 
which  will  illustrate  urethral  fistula  caused  by  injury  inflicted  dur- 
ing; labor. 


964  DISEASES  OF  WOMEN. 

ILLUSTRATIVE    CASE. 

Fistulae  involving  the  Urethra  from  Laceration  or  Sloughing.     (By 
T.  A.  Emmet,  M.  D.) 

First  pregnancy ;  the  head  born  at  the  end  of  seventy-four  hours ;  pains  then  ceased : 
body  delivered  fifteen  hours  afterward  by  traction.  The  urethra  lacerated  entirely 
through,  half  an  inch  from  the  meatus.  The  distal  portion  of  the  canal  so  dilated 
that  a  large  portion  of  the  mucous  membrane  protruded.  The  difficulties  of  the 
operation  consisted  in  passing  the  sutures  so  as  to  bring  perfectly  into  apposition 
the  two  sections  of  the  canal  of  diiferent  diameters.     Operation  successful. 

Mrs.  IL,  aged  eighteen,  was  admitted  from  Cold  Spring,  Long 
Island,  April  27,  1867.  She  had  been  married  two  years,  and  had 
given  birth  to  a  still-born  child. 

Labor  at  full  term  conmienced  Wednesday,  January  24,  1867. 
The  pains,  however,  were  not  very  strong  or  freqnent  until  the 
following  Sunday.  At  2  p.  m.  the  head  was  born,  but  the  pains 
entirely  ceased  afterward,  and  the  body  remained  undelivered  until 
Monday  morning,  when  the  labor  was  terminated  by  tractioiL 

Previous  to  delivery,  the  bladder  had  not  been  emj^tied  for  forty- 
eight  hours ;  four  days  afterward  the  urine  began  to  dribble  away. 
It  was  not  noticed  that  any  sloughs  were  passed  from  the  vagina. 

Pathological  Condition. — Directly  across  the  urethra,  al)out  half 
an  inch  from  the  meatus,  a  fissure  extended  from  one  ramus  to  the 
other,  dividing  the  urethral  canal  entirely  through.  The  distal  por- 
tion of  the  urethra  was  so  dilated  that  the  index-finger  could  be 
introduced  for  some  distance  within  the  canal. 

The  mucous  membrane  anterior  to  the  neck  of  the  l)ladder  pro- 
truded in  a  hypertrophied  mass  as  large  as  an  almond,  resembling  a 
prolapsed  anus.  In  the  center  of  the  prolapse,  the  orifice  of  the 
canal  just  in  front  of  the  neck  of  the  bladder  remained  undilated, 
and  corresponded  in  diameter  to  the  portion  of  the  urethral  canal 
through  tlic  anterior  flap. 

This  condition  was  an  unusual  complication,  as  the  prolapsed 
mass  filled  up  the  sulcus,  and,  although  it  could  easily  be  returned, 
it  was  with  great  difficulty  kept  within  the  canal  for  the  purpose  of 
scarification.  The  temptation  was  strong  to  remove  a  portion  of 
it  with  the  ecraseur,  and  wait  until  the  surface  had  healed  before 
operating;  this  was,  however,  deemed  unadvisable  from  the  extent 
of  cicatricial  tissue,  and  the  uncertain  amount  of  contraction  which 
would  have  resulted. 

Operation. — May  7tli. — The  whole  extent  of  the  sulcus  was 
denuded  around  the  edge  of  the  urethra  on  each  side  with  care,  so 


VESICAL  AND  URETHRAL  FISTULA.  965 

as  not  to  wound  the  mucous  membrane  of  the  canal.  Thirteen 
sutures  were  introduced. 

The  only  point  of  interest  was  in  regard  to  tlie  manner  of  pass- 
ing those  nearest  the  urethra.  The  sutures  1,  2,  and  3  correspond  in 
relation  to  their  entrance  and  exit  on  the  vaginal  surface,  Nos.  2  and 
3  div^erge  from  the  edge  of  the  undilated  portion  of  the  urethra 
to  enter  at  a  corresponding  point  on  the  margin  of  the  dilated 
portion. 

Six  sutures  on  each  side,  from  the  angles  toward  the  urethra, 
were  first  twisted ;  a  large  sound  was  then  introduced  into  the  blad- 
der to  keep  back  the  prolapsed  portion  while  securing  Nos.  2  and  3 
on  each  side  of  the  urethra.  Lastly,  No.  1  was  twisted,  but,  before 
doing  so,  the  slight  prolapse  was  pushed  back  and  kept  from  pro- 
truding by  the  point  of  a  blunt  hook  passed  under  the  suture,  and 
retained  untd  it  was  secured. 

On  reflection,  it  will  be  evident  that,  in  securing  tlie  sutures  on 
each  side  of  the  urethra,  they  must  necessarily  aj^proximate  to  a 
parallel  course  in  relation  to  each  other,  and  in  so  doing  the  excess 
of  tissue  would  be  rolled  thus  into  tlie  bladder.  "While  the  dilated 
outlet  was  doubtless  folded  somewhat  on  itself  between  the  five  sut- 
ures which  embraced  the  diameter  of  the  urethra,  yet,  as  they  were 
passed  so  as  to  bring  the  edges  of  the  canal  at  each  point  into  exact 
apposition,  the  catheter  met  with  no  obstruction,  and  the  excess  of 
tissue  soon  retracted. 

May  17th. — The  sutures  were  removed,  and  the  operation  was 
found  successful. 

May  29th. — A  sound  was  passed  along  the  urethra,  and,  after  a 
careful  examination,  it  was  found  impossible  to  detect  the  line  of 
union,  as  not  the  slightest  irregularity  existed.  The  case  was  dis- 
charged by  Dr.  Emmet,  cured,  June  1,  1867. 

VESICO-UTERINE    FISTULA. 

In  this  variety  of  fistula  the  opening  extends  from  the  bladder 
into  the  utei'us,  usually  into  the  cervix  uteri.  It  is  generally  caused 
during  labor,  in  which  the  anterior  wall  of  the  cervix  is  torn,  and 
the  laceration  extends  into  the  posterior  wall  of  the  bladder. 

During  the  healing  which  follows  the  injury,  the  lower  portion 
of  the  wound  in  the  cervix  heals,  leaving  a  fistulous  communication 
running  from  the  bladder  into  the  canal  of  the  uterus.  The  same 
fistulous  opening  may  be  formed  in  the  operation  for  the  purpose  of 
closing  the  opening  in  the  bladder,  and  at  the  same  time  restoring 


966  DISEASES  OF  WOMEN. 

the  laceration  of  the  cervix.  Union  is  secured  on  the  vaginal  side 
of  the  wound,  but  a  iistulous  opening,  as  described,  is  formed  by 
the  failure  to  obtain  union  in  the  deeper  part  of  the  wound. 

A  case  of  this  kind  has  already  been  quoted  from  Ennnet. 

The  chief  points  of  interest  in  this  form  of  fistula  are  in  diag- 
nosis and  treatment.  The  symptoms  are  the  same  in  tliis  as  in  all 
fistulas  of  the  urinary  tract,  but  the  physical  signs  and  diagnosis 
differ.  No  physical  evidences  of  the  presence  of  the  fistula  are 
obtained  by  examination  with  the  speculum,  except  that  the  urine 
may  be  seen  flowing  from  the  canal  of  the  uterus.  If  the  urine 
does  not  flow  at  the  time  of  the  examination,  the  bladder  should  be 
filled  with  water  colored  witli  carmine,  which  will  escape  through 
the  canal  of  the  uterus,  thus  proving  the  presence  of  tlie  opening. 

To  determine  its  exact  location,  and  obtain  some  idea  of  its  size, 
one  sound  should  be  passed  into  the  bladder  and  another  into  the 
canal  of  the  uterus,  and  by  careful  manipulation  the  points  of  the 
instruments  can  be  made  to  meet.  This  will  show  where  the  open- 
ing is  situated,  and,  by  moving  the  sounds  to  and  fro,  an  idea  of  the 
size  of  the  fistula  can  be  obtained. 

Treatment. — The  method  of  closing  a  fistula  of  this  kind  is  to 
divide  the  cervix  uteri  and  the  vaginal  wall  down  to  the  track  of  the 
fistula,  and  then  pare  the  edges  thoroughly,  taking  care  to  remove 
the  scar  tissue  as  completely  as  possible.  Sutures  are  then  intro- 
duced to  close  the  entire  wound  in  the  bladder,  vagina,  and  cervix. 

I  believe  that  in  this  operation  there  is  more  likelihood  of  hav- 
ing troublesome  haemorrhage  than  in  vesico-vaginal  fistula,  but  it 
can  be  arrested  in  the  way  already  described.  The  following  case 
will  make  the  whole  subject  clear  and  complete. 

ILLUSTKATIVE    CASE. 

A  lady  living  in  the  country  was  delivered  with  forceps  after 
having  been  in  labor  for  forty-eight  hours.  When  the  forceps  were 
used  the  cervix  was  not  fully  dilated,  and  the  operator  stated  that  he 
had  much  trouble  in  applying  the  instrument  and  delivering.  She 
had  incontinence  of  urine  after  her  confinement.  One  year  after- 
ward she  came  under  my  care.  There  was  then  a  sear  running 
down  about  three  quarters  of  an  inch  in  the  vagina,  from  a  partially 
healed  laceration  of  the  anterior  wall  of  the  cervix  uteri.  The  urine 
could  be  seen  flowing  from  the  cervical  canal.  A  sound  passed  into 
the  bladder  entered  the  canal  of  the  cervix  near  the  os  internum^ 
and  could  be  felt  with  another  sound  in  the  canal  of  the  cervix. 

The  operation  was  performed  by  passing  a  sound  through  the 


VESICAL  AND   URETHRAL   FISTULiE.  QQ^ 

bladder  into  the  canal  of  the  cervix,  and  then,  by  cutting  down 
through  on  eacli  side  of  the  scar  tissue,  a  wedge-shaped  piece  was 
removed  which  exposed  the  track  of  the  fistula.  The  edges  of  the 
fistula  were  then  carefully  pared,  and  the  w'ound  closed  with  sutures 
first  introduced  into  the  wound  of  the  bladder  and  vagina,  and  then 
into  the  cervix. 

The  catheter  was  kept  in  the  bladder  for  five  days,  and  at  the 
end  of  the  eighth  day  the  sutures  were  removed,  and  the  union  was 
found  to  be  complete. 


CHAPTER   LIII. 

DISEASES    AND    INJURIES    OF   THE    TEETERS. 

Injuries  to  the  ureters  during  ovariotomy  and  hysterectomy  are 
referred  to  in  the  description  of  these  operations.  The  diseases  of 
the  ureters  caused  by  various  forms  of  cystitis  are  discussed  in  con- 
nection with  diseases  of  the  bladder. 

There  still  remain  for  consideration  the  injuries  of  the  ureters 
which  occur  during  labor,  and  ureteral  affections  caused  by  neo- 
plasms and  other  diseases  of  the  pelvic  organs. 

Affections  of  the  Ureters  due  to  Infiammation  of  the  Pelvic  Perito- 
nseum  and  Cellular  Tissue. — Pressure  from  inllammatory  products 
in  the  pelvic  cellular  tissue  or  on  the  pelvic  jDeritonseum  may  so 
obstruct  the  ureter  as  to  cause  hydro-ureteritis  and  pyelitis,  and,  in 
rare  cases,  fatal  renal  disease.  In  other  cases  the  ureter  may  become 
inflamed  from  the  inflammation  of  the  tissues  surrounding  it.  In 
that  case  obstruction  and  its  consequences  follow  in  natural  order. 
The  completeness  and  the  duration  of  the  obstruction  appear  to  be 
most  marked  when  the  pelvic  inflammation  runs  its  course  very 
rajDidly  and  the  exudate  is  large  and  extensive. 

Syrn2)tomatolo(jy. — The  indications  of  obstruction  of  the  ureter 
are  very  obscure.  The  symptoms  and  physical  signs  of  a  cellulitis 
or  peritonitis  so  fully  command  the  attention  of  the  observer  that 
the  ureter  is  very  often  overlooked.  During  the  progress  of  the 
primary  disease  I  have  observed  that  the  pelvic  pain  and  tenderness 
extended  up  the  tract  of  the  ureter  to  the  kidney,  and  that  the  dis- 
turbance of  tlie  digestive  and  nervous  systems  was  more  severe  than 
the  pelvic  inflammation,  uncomplicated,  accounted  for.  From  this 
it  will  be  seen  that  I  have,  so  far,  been  unable  to  ol)serve  anything 
in  the  symptoms  diagnostic  of  ureteral  obstruction  from  this  cause. 

Phynical  Signs. — Products  of  inflammation  may  sometimes  be 
found  by  an  examination  of  the  urine.  All  that  I  know  of  the 
physical  signs  of  ureteral  diseases  and  the  methods  of  examination 

968 


DISEASES  AND  INJURIES  OF  THE  URETERS.  969 

I  have'Ol)taincd  from  the  writings  of  Professor  Howard  A.  Kelly. 
I  will  therefore  (juote  from  his  article  on  this  subject  in  the  "Trans- 
actions of  the  American  Gynaecological  Society"  for  1888 : 

"  By  I)  I  ^jf  n't  ion.— Inspection  is  the  method  proj)Osed  l>y  Dr.  T, 
A.  Enmiet,  and  is  conducted  by  splitting  the  vesico-vaginal  septum 
and  everting  the  edges  of  the  wound  until  the  ureteral  orifices  are 
exposed,  when  the  ureters  may  also  be  catheterized,  and  their  secre- 
tions compared.  This  method  resembles  the  practice  of  introducing 
a  catheter  into  the  exposed  orifices  of  the  ureters  in  the  margin  of 
a  vesico-vaginal  fistula.  It  is  one  of  value  in  serious  cases  warrant- 
ing operative  interference  ;  nor  is  the  oj^eration,  skillfully  conducted, 
to  be  estimated  as  in  any  way  grave.  The  edges  of  the  incisions 
can  be  brought  together  after  the  examination,  and  the  wound 
healed  at  once. 

^'JSy  Catheterization. — The  method  of  Professor  Karl  Pii),wlik, 
of  Prague,  of  catheterizing  the  ureters  free-handed,  without  prelimi- 
nary preparation  of  the  patient,  beyond  the  occasional  distention  of 
the  bladder  with  a  bland  fluid,  is  the  one  deserving  most  attention. 
This  method  I  have  both  practiced  and  seen  at  the  hands  of  Pro- 
fessor Pawlik  during  the  past  summer  (1888).  The  patient  is  placed 
in  the  dorsal  position,  with  legs  strongly  flexed  on  the  abdomen, 
and  a  Simon  or  Sims's  speculum  introduced,  retracting  the  posterior 
vaginal  wall.  The  eye  at  once  ol)serves  a  series  of  divei'gent  folds 
starting  just  back  of  the  neck  of  the  bladder  and  sweeping  laterally 
and  back  toward  the  cervix  uteri,  corresponding  very  closely  at 
their  point  of  union  to  the  inter-ureteric  ligament,  and  following  in 
general  outline  the  course  of  the  ureters.  A  delicate  catheter,  a  cut 
of  which  is  shown  in  Fig.  290,  is  then  carried  into  the  bladder,  dis- 


tended with  about  four  ounces  of  urine,  and  poised  between  thumb 
and  index-finger.  The  position  of  the  end  of  the  catheter  is  plainly 
noted  by  the  eye,  observing  its  movements  in  the  vagina  as  the  point 
sweeps  gently  along  the  floor  of  the  bladder.  The  ureteral  orifice 
is  to  be  sought  for  about  an  inch  back  of  the  neck  of  the  bladder, 
and  about  half  or  three  quarters  of  an  inch  from  the  median  line 
on  either  side.  This  position  of  the  ureter,  however,  is  not  con- 
stant, and  can  not  be  relied  upon  alone.  Far  more  characteristic  is 
t)ie  slight  tripping  sensation  given  to  the  point  of  the  catheter  as  it 
glides  over  the  ureteral  prominence.     As  soon  as  this  sensation  is 


970  DISEASES  OF  WOMEN. 

perceived,  the  catheter  must  be  at  once  brought  back  to  the  place 
where  it  was  felt,  and  gentle  attempts  made  to  engage  its  point  by 
repeatedly  carrying  the  handle  upward  and  outward,  and  the  point 
consequently  in  the  opposite  direction.  Once  caught,  the  catheter 
sweeps  readily  in,  and,  if  lightly  held,  directs  its  own  course,  the 
lingers  sim[)ly  following.  It  thus  passes  some  distance  unrestrain- 
edly, parallel  to  the  pelvic  wall,  and  the  eye  observes  the  anterior 
vaginal  wall  being  lifted  up  in  advance  and  to  one  side  of  the  cer- 
vix, forming  a  distinct  pocket  on  the  side  on  which  the  ureter  is 
catheterized.  This  is  a  point  to  which  my  attention  was  specially 
called  by  Professor  Pawlik. 

"  On  withdrawing  tlie  stopper  in  the  end  of  the  catheter,  a  few 
drops  of  urine  run  out,  wdien  the  flow  ceases ;  after  a  few  seconds 
a  few  more  drops  run  out,  and  then  cease,  keeping  up  in  this  way 
an  intermittent  discharge  entirely  characteristic.  The  catheter  can 
not  with  safety  be  pushed  beyond  the  brim  of  the  pelvis.  On  with- 
drawing it  the  sudden  drop  of  the  anterior  vaginal  wall  is  very  char- 
acteristic. I  have  found,  as  Pawlik  states,  that  very  slight  force  in 
the  cadaver  is  apt  to  make  false  pockets  in  the  mucosa  of  the  blad- 
der. This  was  especially  marked  in  a  subject  upon  which  I  experi- 
mented this  summer  in  Professor  Yirchow's  laboratory.  The  ureters 
were  displaced  backward  to  an  extreme  degree,  and,  in  sjiite  of  the 
fact  that  I  knew  exactly  where  they  were,  and  the  catheter  would 
constantly  glide  over  the  orifices,  it  was  almost  impossible  to  intro- 
duce it.  I  have  at  other  times  succeeded  in  introducing  it  at  the 
very  first  attempt,  and  yesterday  morning,  in  my  office,  catheterized 
the  right  ureter  of  a  patient  who  did  not  know  that  I  was  doing 
more  than  making  an  ordinary  vaginal  examination.  I  have  made 
a  change  in  Pawlik's  catheter,  substituting  a  series  of  holes  for  the 
long  fenestrum,  which  caught  and  cut  the  mucous  membrane  of  the 
urethra  in  introducing  it  into  the  bladder. 

''''By  Palpation. — The  finger  is  passed  into  the  vagina  be. 
hind  the  internal  orifice  of  the  urethra,  at  the  end  of  the  rugose 
promontory  on  the  anterior  vaginal  wall,  and  carried  with  some 
exertion  up  toward  the  brim  of  the  pelvis,  displacing  the  vaginal 
wall  upward  and  outward  until  the  pulp  of  the  finger  reaches  the 
highest  point  it  can  touch,  often  as  high  as  the  brim,  but  varying 
according  to  the  greater  or  less  laxity  of  the  tissues  and  their  fixa- 
tion by  pelvic  pathological  processes.  It  is  then  carried  downward, 
stroking  the  pelvic  wall,  carefully  estimating  the  character  of  all 
structures  felt  rolling  under  it.  As  soon  as  the  observer  thinks  he 
has  felt  a  ureter,  he  catches  the  cord  again  with  the  hooked  finger 


DISEASES  AND  INJURIES  OF  THE  URETERS.  971 

and  pulls  it  down  a  little,  and  then  slides  the  finger  first  toward  the 
bladder,  where  the  ureter  is  felt  to  lose  itself  at  the  trigoinim,  and 
then  backward,  where  it  loses  itself  sweeping  around  the  cervix.  I 
have  found  that  in  a  certain  number  of  cases  the  ureter  can  be  felt 
most  distinctly  in  this  position  just  in  advance  of  the  cervix,  by- 
placing  the  patient  on  her  left  or  right  side,  when  the  vagina  bal- 
loons out  and  applies  itself  closely  to  that  side  of  the  pelvic  wall 
which  lies  undermost ;  here  the  ureter  can,  by  a  slight  effort  dis- 
placing the  vaginal  vault  upward,  be  hooked  and  brought  down 
under  the  finger,  felt  with  the  utmost  distinctness,  and  compressed. 

"  By  Bimanual  Palpation. — I  found,  after  examining  a  certain 
number  of  cases  in  which  it  was  impossible  to  displace  tlie  vagina 
sufiiciently  to  feel  the  ureter  against  the  pelvic  wall,  or  to  feel  the 
ureter  with  one  hand  lying  like  a  cord  in  the  connective  tissue 
alongside  of  the  vagina,  that  it  was  still  possible  to  outline  its  whole 
course  with  distinctness  by  a  bimanual  examination,  when  it  could 
be  picked  up  between  the  tips  of  two  fingers  and  traced  from  cervix 
to  bladder.  In  speaking  of  this  to  Dr.  Sanger  recently,  he  called 
my  attention  to  the  fact  that  he  had  mentioned  the  bimanual  exami- 
nation, and  stated  that  he  was  daily  more  fully  appreciating  its  possi- 
bilities. The  best  position  to  feel  for  the  ureters  at  the  beginning 
of  the  bimanual  examination  is  in  the  oblique  diameters  of  the  pel- 
vis, bringing  the  tips  of  the  fingers  as  closely  as  possible  together, 
and  rolling  them  to  and  fro,  keeping  near  the  j)elvic  wall,  watching 
for  the  characteristic  sensation,  when  the  cord  may  be  traced  in 
either  direction.  In  late  pregnancy,  the  ureters  are  especially  dis- 
tinct, and  seem  often  to  be  enlarged.  Under  favorable  circumstances, 
a  thickened  ureter  can  be  felt  through  the  thin  abdominal  walls  as 
it  leaves  the  j^elvis  and  crosses  the  brim." 

Treatment. — As  a  matter  of  course,  the  treatment  must  be  chiefly 
directed  to  the  primary  inflammation  which  caused  the  obstruction 
of  the  ureter. 

I  am  satisfied  that  in  many  of  the  cases  recovery  takes  place  with- 
out any  direct  or  specific  treatment.  Should  the  ureteral  disease  per- 
sist, relief  may  be  obtained  by  catheterizing  and  dilating  the  ureter 
and  washing  it  out  with  a,  mild  solution  of  borax  or  sulphate  of  zinc. 

Obstruction  of  the  Tlreters  by  Uterine  and  Ovarian  Neoplasms. — It 
may  be  stated  here  that  the  ureters  become  occluded  most  frequentl}^ 
in  patients  suffering  from  cancer  of  the  uterus  in  its  last  stages.  I 
have  seen  several  such  patients  die  from  ursemia.  There  is  but  little 
that  can  be  done  for  their  relief,  and  hence  nothing  more  need  be 
said  on  this  subject. 


972  DISEASES  OF  WOMEN. 

Obstruction  of  the  Ureters  due  to  Uterine  Fibromata. — I  have  sev- 
eral  times  seen  this  condition.  The  symptoms  are,  pain  on  the 
affected  side  (one  ureter  only  is  obsti'ucted,  as  a  rule) ;  the  pain 
extends  upward  in  the  line  of  the  ureter  to  the  kidney,  a  dull,  aching 
pain  in  the  back  on  that  side  ;  there  is  usually  tenderness  on  press- 
ure, and  often  a  slight  sensitiveness  on  bimanual  examination  of  the 
kidney  on  the  affected  side ;  by  that  I  mean,  when  one  hand  is 
placed  on  the  back  and  the  other  on  the  abdomen,  and  pressure  is 
made  over  the  kidney  with  both  hands.  Digital  examination  of  the 
vagina  reveals  nothing  of  value  except  tenderness.  The  treatment 
in  this  condition  must  largely  be  directed,  as  in  obstruction  from 
other  causes,  to  the  neoplasm  that  gives  rise  to  it.  If  the  fibroid  is 
impacted  in  the  pelvis,  efforts  should  be  made  to  raise  it  up  into  the 
abdominal  cavity.  Electricity  should  be  employed  in  mild  cases; 
Ijut  when  there  is  danger,  land  relief  is  not  obtained,  hysterectomy 
should  be  resorted  to.  Indeed,  I  consider  this  as  one  of  the  most 
important  indications  for  the  removal  of  the  uterus. 

ILLUSTRATIVE    CASES. 

Obstruction  of  the  Ureter  from  Pelvic  Cellulitis. — The  j^atient  suf- 
fered from  mcnorrhagia  ;  a  sponge  tent  was  used  to  dilate  the  cervix, 
after  which  curetting  was  performed.  This  was  before  I  knew  how 
dangerous  and  useless  such  tents  were,  and  before  antisej^tic  surgery 
was  fully  practiced  and  taught.  The  result  was  a  circumscribed  cel- 
lulitis on  the  left  side.  About  the  fifth  day  the  constitutional  symp- 
toms increased  decidedly,  and  the  pain  extended  upward  on  the  left. 
There  was  dithculty  in  urinating,  and  the  catheter  was  used.  The 
urine  was  at  first  clear,  but  rather  abruptly  became  turbid.  This 
led  to  an  examination  which  showed  the  presence  of  pus.  I  sup- 
posed that  a  cystitis  had  been  caused  by  the  use  of  the  catheter,  but 
further  investigation  proved  that  the  pus  came  from  the  ureter  and 
kidney.  The  case  was  under  observation  at  the  time  M'hen  I  was 
learning  how  to  tell  when  pus  or  blood,  that  was  found  in  the  urine, 
came  from  the  bladder  or  kidney ;  and,  on  that  account,  I  made  a 
number  of  examinations,  all  of  which  indicated  that  the  trouble  was 
in  the  ureter  and  })elvis  of  the  kidney.  A  friend,  who  also  ex- 
amined the  urine,  made  the  diagnosis  of  pyelitis  and  acute  nephritis. 
The  cellulitis  ended  in  resolution,  and  the  patient  recovered  and  has 
remained  in  good  health. 

Obstruction  of  the  Ureter  from  Uterine  Fibroma. — A  lady  forty- 
three  years  old,  who  liad  a  very  large  uterine  fibroma  which  she  had 
carried  for  years  without  being  much  embarrassed  by  it,  was  taken 


DISEASES  AND  INJURIES  OF   THE  URETERS.  973 

with  backache  and  some  ill-defined  constitutional  symptoms,  which 
for  the  first  time  compelled  her  to  give  np  her  duties  to  a  great  ex- 
tent, but  she  did  not  seek  medical  aid.  She  died  suddenly,  after  a 
convulsion,  which  was  not  very  well  described  by  the  friends  who 
were  with  her  at  the  time.  In  fact,  there  was  no  clear  history  ob- 
tainable. Post-mortem,  I  fonnd  a  large  fibroid,  and  in  tlie  cellular 
tissue  aronnd  the  npper  part  of  the  cervix  uteri  there  was  much 
oedema,  and  what  looked  like  an  exudation.  Both  ureters  were 
dilated,  and  there  were  hydro-nephrosis  and  acute  nephi-itis.  All 
the  other  organs  of  the  l)ody  were  normal. 

Injuries  to  the  Ureters  during  Labor. — While  engaged  in  obstetric 
practice,  both  hospital  and  jirivate,  I  attended  several  cases  which 
differed  from  any  of  the  puerperal  diseases  i-ecorded  in  obstetrical 
literature. 

During  the  early  years  of  my  investigation  very  little  was  learned 
about  these  cases  except  that  there  was  something  in  their  pathology 
which  was  not  known  to  me.  The  manifestations  of  the  affection, 
as  observed  clinically  and  at  post-mortem  examinations,  led  me 
eventually  to  infer  that  injury  to  the  ureters  during  parturition  was 
the  cause  of  the  phenomena  which  I  witnessed  in  these  cases. 

Pathology. — From  a  considerable  study  of  the  subject  clinically, 
and  a  meager  one  of  its  morbid  anatomy,  I  feel  warranted  in  stating 
that  the  pathology  of  this  affection  is  a  contusion  or  laceration  of 
one  of  the  ureters  by  the  head  of  the  child,  the  hand  of  the  obstet- 
rician, or  more  often  by  the  forceps.  This  contusion  gives  rise  to 
swelling  of  the  walls  of  the  ureter  and  the  cellular  tissue  around 
it,  and  perhaps  some  degree  of  inflammation.  This  is  suflficient  to 
obstruct  the  ureter  and  cause  hydro-nephrosis,  and  subsequently  pye- 
litis. As  the  swelling,  and  perhaps  inflammation,  at  the  point  of 
original  injury  subside,  the  pressure  of  the  urine  and  pus  above 
forces  a  way  through  the  ureter,  and  relief  follows.  This  is  the  ex- 
planation of  the  sudden  discharge  of  pus  with  the  urine.  In  case 
the  obstruction  lasts  long,  the  kidneys  become  involved  to  an  extent 
that  varies  according  to  the  duration  of  the  obstruction.  Whenever 
the  ureter  is  completely  blocked  and  remains  so,  there  is  nephritis, 
and  then  acute  ursemia,  which  may  prove  fatal,  as  already  stated. 

In  a  given  number  of  cases,  there  are  some  in'which  there  is  cys- 
titis, but  no  marked  disease  of  the  kidneys.  In  others,  the  bladder 
is  not  involved,  but  the  kidney  is ;  while  in  others  all  three  organs — 
bladder,  ureter,  and  kidney — are  affected.  When,  as  is  not  infre- 
quently the  case,  there  are  some  of  the  usual  injuries  of  the  cervix 
uteri  and  pelvic  floor,  and  metro-cellulitis  follows,  the  ureters  become 


974  DISEASES  OP  WOMEN. 

secondarily  affected.  Under  such  circumstances  the  order  of  de- 
velopment of  the  pathological  lesions  is  reversed  to  some  extent,  and 
lience  the  clinical  history  is  changed,  so  that  the  ureteral  obstruction 
and  consequent  renal  disease  come  later  and  generally  are  less  dan- 
gerous, owing  to  being  less  acute  and  of  shorter  duration. 

Causation. — Predisposing  Causes. — There  are  certain  conditions 
which  predispose  to  injuries  of  the  ureters  during  labor.  When  the 
bladder  and  terminal  ends  of  the  uretera^rest  low  in  the  pelvis  toward 
the  end  of  gestation,  there  is  more  liability  of  their  being  caught 
between  the  child's  head  and  the  brim  of  the  pelvis  during  labor. 
In  many  cases  the  ureters  suffer  some  impairment  of  nutrition  dur- 
ing gestation  (and  are  more  susceptible  to  injury)  that  is  produced 
by  passive  hypersemia  and  oedema,  and  hence  a  softened  state  of  the 
pelvic  tissues  follows.  There  is  in  such  cases  a  want  of  elasticity 
and  resistance  to  injury.  This  is  seen  in  the  friable  condition  of  the 
cervix  uteri,  vagina,  and  pelvic  floor,  which  renders  them  so  easily 
damaged.  In  brief,  then,  the  location  of  the  bladder  and  ureters, 
the  pre-existing  lesion  or  functional  derangement  of  the  ureters,  and 
malnutrition  of  the  tissues  in  the  pelvis,  are  the  conditions  which 
predispose  to  graver  injuries  during  labor. 

Direct  Causes. — The  fact  that  the  uretei's  escape  injury  when 
dilatation  of  the  cervix  uteri  is  complete  before  expulsion  proceeds, 
gives  a  clew  to  the  causation  of  such  injuries.  When  the  mem- 
branes rujiture  before  dilatation  is  complete,  and  consequently  the 
cervix  uteri  and  bladder  are  carried  down  into  the  pelvis  before  the 
advancing  head,  the  ureters  are  exposed  to  undue  jjressure  and 
traction  also,  and  hence  are  sure  to  be  more  or  less  injured.  The 
dangers  are  much  greater  when  it  is  necessary  to  use  the  forceps  or 
perform  version  under  these  circumstances.  The  presence  of  hard 
fiecal  matter  in  the  rectum  may  also  be  mentioned  among  the  causes. 
Faulty  methods  of  operating  no  doubt  add  to  the  dangers.  Undue 
lateral  motion  of  the  forceps  during  extraction  must  certainly  do 
more  or  less  damage  to  the  adjacent  tissues  and  ureters.  Especially 
is  this  likely  to  occur  if  the  cervix  uteri  and  bladder  are  permitted 
to  descend  before  the  advancing  head. 

Symptomatology . — The  patients  are  usually  primiparae,  or  at 
least  have  not  had  many  children,  the  labor  tedious,  instrumental  or 
manual,  and  the  progress  after  delivery  fairly  satisfactory  for  several 
days.  The  lochial  discharge  may  be  normal,  and  the  secretion  of 
milk  also.  The  bowels  may  act  well,  and  the  kidneys  apparently  so. 
In  some  patients  there  is  retention  of  urine  or  frequent  and  painful 
urination.     Pelvic  pain  and  tenderness  in  the  lower  part  of  the 


DISEASES  AND  INJURIES  OP  THE  URETERS.  975 

abdomen  are  present,  but  are  not  always  sev^ere  at  first.  These 
symptoms  become  more  acute  after  a  time,  the  pain  and  tenderness 
increase  rather  abniptly,  and  a  chill  or  rigor  may  occur ;  distention 
of  the  bowels  takes  place,  the  temperature  runs  up,  and  tlie  pulse  is 
also  increased  in  frequency. 

An  increase  in  the  severity  of  the  symptoms  supervenes  in  from 
three  to  five  days,  and  soon  thereafter  a  quantity  of  pus,  and  some- 
times blood,  appears  in  the  nrine.  When  the  discharge  of  pus 
begins,  the  patient  is  generally  relieved  to  some  extent.  The  pain 
is  less,  and  the  temperature  and  pulse  are  reduced  a  little.  In  con- 
nection with  pus  and  blood  renal  casts  may  be  found,  but  this  is  not 
invariably  the  case.  The  pus  continues  to  be  discharged  in  dimin- 
ished quantity  for  a  week  or  more.  The  bleeding  generally  subsides 
in  a  day  or  so,  and  most  of  the  cases  gradually  recover.  In  others, 
acute  disease  of  the  kidney  appears  about  the  time  that  the  pus  be- 
gins to  be  discharged  fi-om  the  bladder,  and  uraemia  follows,  and 
sometimes  uroemic  coma.  Such  cases  end  fatally,  as  a  rule,  but  I 
have  known  one  to  recover. 

Physical  Sigiis. — There  is  tenderness  to  the  touch  along  the 
line  of  the  nreter,  and  bimanual  manipulation  of  the  kidney  upon 
the  affected  side  usnally  causes  a  sense  of  distress  rather  than 
pain.  In  nncomplicated  cases  a  vaginal  examination  gives  nega- 
tive signs,  except  that  tenderness  is  detected  high  np  on  the  side 
involved. 

The  diagnosis  of  injuries  of  the  ureters  must  be  made  by  the 
exclusion  of  the  more  common  puerperal  affections,  such  as  peri- 
tonitis, cellulitis,  or  general  septicaemia.  Metiitis  is  excluded  on 
the  grounds  that  the  lochia  are  normal,  that  tliei-e  is  absence  of  ten- 
derness, and  that  involution  progresses  as  it  should.  The  sympto- 
matic fever  is  too  mild  in  character  to  indicate  general  peritonitis, 
and  the  physical  signs  of  that  affection  are  wanting.  The  tenderness 
on  pressure  on  the  side  affected,  and  the  constitutional  disturbance 
not  otherwise  accounted  for,  are  suggestive  of  cellulitis,  but  the  evi- 
dence, so  far  as  relates  to  physical  signs,  of  that  affection  is  insufii- 
cient,  and  the  subsequent  history  effectually  excludes  it. 

The  sudden  appearance  of  pns  and  blood  in  the  urine  leads  one 
to  suspect  that  an  abscess  has  formed  in  the  cellular  tissue  and  dis- 
charged into  the  bladder.  This  condition  is  excluded  on  the  ground 
that  there  have  been  no  physical  signs  of  cellulitis;  and,  further- 
niore,  an  abscess  never  discharges  into  the  bladder  in  so  short  a  time 
after  the  inception  of  pelvic  cellulitis. 

In  cases  complicated  with  traumatic  cystitis,  it  might  be  pre- 


976  DISEASES  OF  WOMEN. 

sumed  that  an  abscess  had  formed  in  the  wall  of  the  bladder ;  but 
that  is  excluded  for  the  reason  that  the  violent  symptoms  and  physi- 
cal signs  found  in  traumatic  and  interstitiid  cystitis  are  absent.  In 
short,  the  history  of  injury  to  the  urettrs  differs  from  that  of  all 
the  puerperal  diseases  hitherto  described  in  medical  literature,  so  far 
as  I  know. 

Prevention. — These  injuries  being  difficult  to  manage,  their  pre- 
vention is  of  prime  importance.  When  the  presence  of  renal 
trouble  is  detected  before  labor,  and  it  is  presumably  due  to  partial 
obstruction  of  the  ureters,  much  may  be  done  by  rest  in  the  recum- 
bent position,  and  the  judicious  use  of  cathartics,  diuretics,  and  vaginal 
douches.  By  improving  the  circulation  and  general  nutrition  of  the 
organs  and  tissues,  the  existing  ureteral  trouble  may  be  relieved  and 
further  injuries  avoided.  During  labor  much  may  be  accomplished. 
Full  dilatation  of  the  cervix  before  rupture  of  the  membranes,  so 
that  the  bladder  and  ureters  may  rise  out  of  the  pelvis  when  the 
head  descends,  yisures  comparative  safety.  In  view  of  these  facts 
the  judicious  obstetrician,  being  fairly  conscious  of  the  danger  to 
the  ureters,  will  find  an-  additional  reason  for  looking  after  their 
interests 

My  attention  was  first  given  to  this  matter  in  order  to  save  the 
bladder  from  contusions  and  disj^lacements,  and  later  I  found  that 
this  w^as  one  of  the  surest  ways  of  saving  the  ureters  also. 

I  have  many  times  called  attention  to  the  necessity  of  supporting 
the  bladder  during  labor,  and  indirectly  the  ureters  also,  but  so  much 
attention  is  bestowed  upon  management  of  the  perin.pum,  that  tlie 
more  important  dangers  to  the  urinary  organs  are  very  largely 
ignored.  This  supporting  of  the  parts  during  labor  should  be  more 
carefully  watched  when  delivery  with  forceps  is  practiced. 

Lacerations  of  the  cervix  uteri  and  pelvic  floor  are  unfortunate 
complications,  but  they  do  not  compare  with  injuries  of  the  ureters 
in  gravity  of  results.  The  fact  is,  that  the  possible  danger  to  the 
ureters  has  not  occurred  to  obstetricians,  as  a  rule,  but  when  fully 
appreciated  will  have  due  attention.  The  lateral  motion  of  the  for- 
ceps, referred  to,  is  happily  not  necessary,  nor  is  it  practiced  by 
experts,  I  believe ;  still  it  should  be  avoided,  for  the  sake  of  the 
ureters  as  well  as  for  the  reasons  given  in  obstetric  works.  This 
would  T)e  an  uncalled-for  statement,  svere  it  not  for  the  fact  that 
wdiile  the  science  of  obstetrics  is  most  mature,  and  the  art  is  practiced 
by  the  few  in  a  perfect  way,  yet  the  practice  of  the  many  is  often 
insufficient,  to  say  the  least. 

Treatment. — The  management  of  injuries  of  the  ureters  which 


DISEASES  AND  INJURIES  OF  THE  URETERS.  977 

have  occurred  is,  I  fear,  in  a  very  immature  state.  At  least,  I  liave 
never  read  or  heard  of  any  suggestion  regarding  treatment,  and  can 
only  give  the  results  of  personal  observation. 

Being  without  precept  or  example,  and  for  years  not  knowing 
the  j^athology  of  the  cases  under  observation,  I  treated  them  as  in- 
flammatory affections,  without  special  regard  to  the  location  and 
character  of  the  inflammation,  for  they  were  unknown.  When  a 
clear  comprehension  of  the  nature  of  the  affection  was  obtained,  the 
treatment  was  still  rather  expectant.  There  is  one  thing  which  has 
appeared  to  be  of  advantage,  and  that  is,  keeping  the  bowels  free. 
In  fact,  free  catharsis  may  be  tried  if  the  patient  is  able  to  stand  it. 
This  I  discovered  by  seeing  a  case  in  consultation,  in  which  the  at- 
tending physician,  suspecting  septicaemia  or  obscure  peritonitis,  had 
adopted  the  modern  treatment — saline  cathartics.  The  results  were 
good,  and  I  feel  confident  that  it  is  a  useful  treatment.  When  the 
bladder  is  involved,  much  is  gained  by  washing  it  out  repeatedly ; 
this  relieves  the  ])ain  in  the  ureter  and  kidney  to  some  extent. 
Retention  of  the  urine  for  an  unusual  length  of  time  increases 
the  suffering,  and  no  doubt  also  the  traumatic  inflammation.  The 
catheter  does  much  good  if  used  by  a  skilled  nurse  or  obstetrician. 
The  unclean  metallic  catheter,  in  general  use  when  I  first  observed 
such  cases,  always  did  harm.  Hot  vaginal  douches  have  been  tried, 
and  when  they  relieve  pain  they  are  curative  ;  but  when  they  increase 
the  suffering  at  the  time  of  their  use,  or  immediately  after,  as  is 
often  the  case,  harm  may  result.  In  a  word,  the  treatment  has  been 
to  relieve  pain,  sustain  the  patient,  and  trust  that  the  damages  would 
be  repaired  before  the  kidneys  were  fatally  involved.  The  question 
of  surgical  treatment  has  occupied  some  time  and  thought,  without 
my  arriving,  however,  at  any  definite  conclusions. 

Catheterizing  the  injured  ureter  seemed  to  be  indicated,  but  I  had 
had  no  experience  with  it  in  acute  injuries,  because  I  gave  up  ob- 
stetrics about  the  time  that  the  practice  of  catheterizing  the  uretei's 
was  introduced,  and  I  had  not  acquired  facility  in  the  operation ; 
and,  lastly,  I  doubted  the  safety  of  such  treatment,  and  felt  that  it 
should  be  tried  by  an  expert  first,  if  at  all. 

In  the  class  of  cases  due  to  inflammation  of  the  tissues  around 

the  ureter,  the  use  of  the  catheter,  in  the  hands  of  an  expert  would 

be  of  the  greatest  value.     This  has  been  proved  by  Kelly,  Engel- 

mann,  and  others.    But  when  the  ureter  is  the  primary  subject  of  the 

injury,  it  is  doubtful  whether  catheterization  would  be  possible,  and 

there  would   be  much  danger  of  the  instrument  perforating  the 

ureteral  wall. 

63 


978  DISEASES  OP  WOMEN. 

ILLUSTRATIVE    CASE. 

The  history  of  this  patient,  from  the  time  of  her  confinement 
until  her  death,  was  characterized  by  the  symptoms  and  signs  whicli 
are  given  above. 

The  patient  died  two  weeks  after  confinement,  and,  post-mortem, 
I  found  an  injury  of  the  left  ureter  about  an  inch  and  a  half  above 
its  lower  end.  Its  walls  were  so  broken  down  that  they  could  not 
be  separated  from  the  surrounding  tissue.  The  ureter  was  occluded 
at  the  point  of  injury.  There  was  a  circumscribed  exudation  in  the 
cellular  tissue  around  the  injured  part.  Suppuration  had  begun  at 
the  site  of  injury,  showing  that  the  starting-point  of  the  inflamma- 
tion was  a  traumatism  of  the  ureter.  Above  the  occluded  portion 
the  ureter  was  dilated,  and  filled  with  pus  and  urine.  There  was 
acute  nephritis  on  that  side,  together  with  inflammation  of  the  ureter 
on  the  right  side,  and  some  infiltration  of  the  cellular  tissue  around 
it.  The  right  kidney  was  also  inflamed,  or  at  least  markedly  hyper- 
ffimic.  Circumscribed  cystitis  of  a  mild  character  existed.  There 
was  not  enough  in  the  clinical  history,  nor  in  the  lesions  found,  to 
indicate  a  grave  form  of  septicsemia.  The  cause  of  death  was,  no 
doubt,  uraemia. 


i:^DEX. 


Acute  endometritis,  183. 

ovaritis,  485. 
After  treatment  of  vesico-vaginal  fistula, 

960. 
Albert  Smith  pessary,  333. 
Alexander's  operation,  328,  339. 
Allantois,  82. 
Amenorrhcea,  52. 
Amputation  of  cervix  uteri,  418. 
Anaesthesia  in  diagnosis,  19. 
Anassthetics,  mode  of  administration,  19. 
Anatomy  of  bladder,  659. 

cervix,  660. 

coats,  660. 

corpus,  660. 

form,  660. 

fundus,  660. 

glands,  661. 

intei'-ureteric  ligament,  662. 

ligaments,  669. 

nervous  supply,  663. 

openings,  662. 

ostium,  urethral,  662. 

position,  660. 

relations  to  urethra,  668. 

sphincter,  vesical,  661. 

trigone,  660. 

ureters,  662. 

vascular  supply,  663. 
of  Fallopian  tubes,  586. 

coats,  586. 

length,  586. 

orifices,  586. 

relation  to  uterus  and  broad  liga- 
ments, 586. 
of  ovaiy,  469. 

blood-supply,  471. 

minute  anatomy,  474. 


Anatomy  of  ovary,  ovulation,  477. 

relation  to  broad  ligament,  470.. 

thickness,  469. 

weight,  469. 

width,  469. 
of  pudendum,  77. 

clitoris,  77. 

glands,  77. 

hymen,  82. 

labia  majora  and  minora,  76. 

vestibule,  78. 
of  urethra,  663. 

coats,  664. 

diameter,  663. 

length,  663. 

meatus  urinarius,  666. 

relation  to  bladder,  668. 

Skene's  glands,  664. 

sphincter,  667. 
of  uterus,  177. 

arbor-vitse,  180. 

body,  177. 

cavity,  178. 

cervix,  177. 

fundus,  177. 

length,  177. 

mucous  membrane  of  cavity,  178. 

mucous  membrane  of  cervical  canal, 
180. 

Nabothian  glands,  180. 

OS  externum,  178. 

OS  internum,  178. 

peritoneal  covering,  178. 

utricular  glands,  179. 

walls,  178. 

width,  177. 
of  vagina,  100. 

coats,  101. 


979 


980 


DISEASES  OF   WOMEN. 


Anatomy  of  vagina,  connection  with  cer- 
vix uteri  and  pelvic  floor,  100. 
length  of  walls,  100. 
orificium,  81. 
Anteflexion  of  the  uterus,  54,  56. 
acquired,  57. 
causation,  61. 
congenital,  57. 
illustrative  cases,  71. 
of  body,  58. 
of  cervix,  57. 
of  cervix  and  body,  58. 
pathology,  58. 
physical  signs,  60. 
symptomatology,  59. 
treatment,  64. 

Elliott's  adjuster,  67. 
pessaries,  67. 
surgical  methods,  64. 
Anterior-labial  hernia,  93. 
Anus,  atresia  of,  83. 
Arbor-vitae  uterina,  180. 
Areolar  hyperplasia  of  uterus,  225. 
Atlee,  W.L.,  319. 
Atresia  of  anus,  83. 
of  vagina,  102. 
of  vulva,  83. 
Atrophy  of  muscular  tissue  of  vaginal 
walls    from    abuse    of     pessaries, 
346. 
of  uterine  walls,  343. 

Bimanual  method  of  examination,  8. 
Bladder,  anatomy  of,  659. 

atrophy,  871. 

development  of,  670. 

diseases,  702. 

dislocation  of,  812. 

distended,  498. 

foreign  bodies,  831. 

function  of,  696. 

haemorrhage  from,  756. 

hernia  of,  823. 

hyperemia  of,  754. 

hyperplasia,  869. 

malformations  of,  677. 

neoplasms,  858. 

paralysis  of,  723. 

rui)ture  of,  847. 
Bleeding  disease  of  uterus,  363. 
Bulbi  vcstibuli,  79. 
Byrne's  galvano-cautery,  417. 


Calculus,  834. 
Cancer,  403. 
of  cervix,  403. 
of  body  of  uterus,  421. 
causation,  422. 
diagnosis,  422. 
pathology,  421. 
physical  signs,  421. 
I)rognosis,  422. 
symptomatology,  421. 
treatment,  422. 
vaginal  hysterectomy,  422. 
Carcinoma,  403. 
Carunculag  myrtiformes,  82. 
Catheter,  use  of,  143. 
Catheterization  of  ureter,  750,  969. 
Cauliflower  excrescence  of  cervix  uteri, 

406. 
Cautery  clamp,  548. 

Paquelin's,  115. 
Cervical  canal  of  uterus,  180. 
Cervical  endometritis,  183. 
exanthematous,  182. 
gonorrhoea),  183. 
puerperal,  182. 
Cervix  uteri,  hypertrophy  of,  350. 
laceration  of,  from  parturition,  244. 
operation  for  restoration  of,  254. 
Chlorosis,  40. 

Chronic  corporeal  endometritis,  207. 
cystitis,  767. 

cervical  endometritis,  184. 
Chronic  inversion  of  uterus,  278. 

ovaritis,  492. 
Cicatrices  of  cervix  uteri  and  vagina,  264. 
causation,  264. 
Illustrative  cases,  264. 
symptomatology,  264. 
treatment,  265. 
Clamp,  hasmorrhoid,  160. 
Classification  of  neoplasms  of  ovary,  506. 
Clitoris,  78. 

Cloaca,  83.  • 

Coccyodynia,  172. 
causation,  173. 
illustrative  cases.  174. 
pathology,  172. 
physical  signs,  173. 
prognosis.  173. 
symptomatology,  172. 
treatment,  173. 
Nott's,  173. 


INDEX. 


981 


Coccyodynia,  treatment.  Simpson's,  173. 

Coccyx,  removal  of,  173. 

Condyloma,  411. 

Corporeal  endometritis,  207. 

Corpus  clitoridis,  78. 

Courty's  method   of  restoring   inverted 

uterus,  279. 
Croupous  cystitis,  808. 
Curette,  21,  204,  362. 
Curetting,  method  of,  214. 
Cusco's  speculum,  11. 
Cylindrical-celled  epithelioma,  406. 
Cystic  degeneration  of  cervix  uteri,  186. 
Cystitis,  754,  761. 

acute,  716. 

causation,  783. 

chronic,  767. 

croupous,  808. 

diagnosis,  778. 

diphtheritic,  808. 

epi-cystitis,  761. 

gonorrhoeal,  761. 

pathology,  762. 

symptomatology,  771. 

treatment,  788. 
Cysto-carcinoma,  506. 
Cysto-fibroma,  513. 
Cysto-sarcoma,  506. 
Cystoscope,  746-750. 
Cysts  of  vagina,  110. 

Depressor,  Hunter's,  14. 
Dermoid  cysts,  512. 
Development  of  bladder,  670. 

of  Fallopian  tubes,  22. 

of  ovaries,  472. 

of  sexual  organs,  22. 

of  urethra,  670. 

of  urinary  organs,  22. 

of  uterus — primary,  22. 
secondary,  24. 

of  vagina,  22. 
Dilatation  of  cervix  uteri,  69. 

of  urethra,  9,  908. 
Dilators  : 

Goodell's,  17. 

Hanks's,  17. 

uterine,  17. 
Diseases  of  Fallopian  tubes,  586. 

of  ovaries,  469. 

of  pudendum,  85. 

of  urethral  glands,  873. 


Diseases  of  urethra,  873. 

of  vagina,  100. 
Dislocation  of  urethra,  920. 
Displacements  of  ovaries,  500. 

of  uterus,  292. 
Double  vagina,  101. 
Drainage  in  ovarian  tumor,  564. 
Ducts,  Miiller's,  22. 
Dudley's  method  of  treating  fistula  in 

ano,  170. 
Dupuytren's  operation  for  atresia,  104. 
Dysmenorrhosa  :  inflammatory,  209. 

membranous,  234. 

neurotic,  60. 

obstructive,  60. 

ovarian,  487. 

Bcraseur,  373. 
Ectopic  gestation,  650. 
Electrolysis,  371. 

in  the  treatment  of  fibroids,  371. 
Elliott's  uterine  adjuster,  67. 
Endometritis,  182. 
senile,  458. 
Epithelioma,  microscopical  appearances, 
406. 
of  the  cervix  uteri,  406. 
pathology,  406. 
pavement-celled,  406. 
physical  signs,  409. 
rodent  ulcer,  406. 
secondary  invasion,  407. 
symptomatology,  407. 
treatment,  417. 
amputation,  417. 
galvano-cautery,  417. 
local,  417. 
Erosions  of  cervix  uteri,  411. 
Eruptions  of  vulva,  98. 
diphtheria,  99. 
eczema,  98. 
acute,  98. 
chronic,  98. 
treatment,  98. 
erysipelas,  98. 

treatment,  99. 
gangrene,  99. 
causation,  99. 
prognosis,  99. 
treatment,  99. 
herpes,  98. 
noma,  99. 


9S2 


DISEASES  OF   WOMEN. 


Eruptions  of  vulva,  prurigo,  98. 

treatment,  98. 
Erythema  of  vulva,  85. 
Ether  inhaler,  19. 
Examination  of  patients,  7. 
anaesthesia,  19. 

method  of  administration,  19. 
aspirator,  17. 
classification  of  facts,  4. 
concave  mirror,  18. 
curette,  16. 

Recamier's,  16. 

Skene's,  16. 
dilators,  Goodell's,  17. 

Ilanks's,  17. 

uterine,  17. 
examining  table,  8. 
history  of  reproduction,  7. 
inspection,  3. 

investigation  of  diseases  of  sexual  sys- 
tem, 5. 
microscope,  18. 
palpation,  10. 
palpation  and  percussion  conjoined,  10. 

diametrical  method,  10. 

fluctuation,  10. 

interrupted  pressure.  10. 

peripheral  method,  10. 
percussion,  10. 
physical  signs,  17. 
position,  11. 

dorsal,  8. 

Sims's,  11. 
resume  of  methods.  19. 
sound  and  palpation  combined,  16. 
sound  and  probe,  14. 

elastic,  15. 

•Jenks's,  15. 

Simpson's,  14. 

Sims's,  15. 
speculum.  11. 

Cu.sco's  bivalve,  11. 

Sims's,  11. 

introduction,  13. 
movements,  13. 
symptomatology,  6. 
tents,  17. 

compressed  sponge,  17. 

sea-tangle,  17. 

tupelo,  17. 
touch,  8. 

bimanual,  9. 


Examination  of  patients,  touch,  by  dila- 
tation of  urethra,  9. 

rectal,  10. 

Simon's  method,  9. 

single,  8. 

TOsico-rectal,  9. 

vesico-vaginal,  10. 
Excrementitious  plethora,  450. 
External  genital  organs,  77. 
Extroversion  of  bladder,  686. 

Facts,  classification  of,  4. 
Fallopian  tubes,  586. 
anatomy,  586. 
anomalies,  586. 
development,  22,  586. 
diseases  of,  586. 
hjematosalpinx,  591. 
laparo-salpingotomy,  591. 
tuberculosis  of,  590. 
Fibroma  of  the  ovary,  513. 
of  uterus,  356. 
synonyms,  356. 

bleeding    disease    of    the    uterus 

(Duncan),  356. 
fibroid,  356. 
fibrous  myoma,  356. 
fibro-myoma,  356. 
hysteroma,  356. 
varieties,  357. 

conglomerate.  358. 
interstitial,  357. 
multiple,  358. 
single,  358. 
submucous,  357. 
subperitoneal,  357. 
within  folds  of  broad  ligament,  357. 
calcareous  degeneration,  360. 
causation,  367. 
clinical  history,  359. 
density,  359. 
diagnosis,  366. 

effects  of,  upon  the  uterus,  361. 
fatty  transformation,  C60. 
osseous  degeneration,  360. 
physical  signs,  365. 
prognosis,  368. 
symptomatology,  363. 
treatment.  369. 
medicinal.  370. 

ergot.  370. 
surgical,  373. 


INDEX. 


983 


Fibroma  of  uterus,  surgical  treatment, 
curette,  373. 
ecriiseur,  373. 
electrolysis,  371. 
hysterectomy,  abdominal,  377. 

supra-vjiirinal,  375. 
Keith's  cases.  394. 
ovariotomy.  544. 
traction  and  morcellation,  381. 
Fissure,  vesico-urethral,  888. 
Fistula  in  ano.  167. 
operation,  167. 

Dudley's,  170. 
treatment,  167. 
new  method,  171. 
urethral,  927,  963. 
vesico-vaginal,  950. 
Flexions  of  the  uterus,  54.    • 
causation,  61. 
diagnosis,  61. 
pathology,  58. 
physical  signs,  60. 
symptomatology,  59. 
treatment,  64. 
varieties,  57. 
Fluctuation,  10. 
Foreign  bodies  in  bladder,  831. 
calculus,  834. 
causation,  835. 
diagnosis,  834. 
prognosis,  835. 
symptomatology,  837. 
treatment,  836. 
hydatids,  833. 
in  urethra,  875. 
Fossa  navicularis,  79. 
Fourchette,  77. 
Frajnulura  vulvje,  77. 
Function  of  bladder,  696. 
Functional  diseases  of  bladder,  702. 
derangements   of    function  in   which 
there   is  no  recognizable  organic 
lesion,  703, 
causation,  709. 
diagnosis,  708. 
illustrative  cases,  712. 
neuroses,  703. 
due  to  disorders  of  sexual   func- 
tions, 704. 
due  to  hysteria,  703. 
due  to  malaria,  705. 
due  to  ovarian  affections,  706. 


Functional    diseases   of    bladder,   prog- 
nosis, 708. 
symptomatology,  707. 
treatment,  709. 

derangements  of  function  due  to  dis- 
eases cf  the  nutritive  and  nervous 
systems.  723. 
paralysis,  723. 
causation,  726. 
diagnosis,  725. 
enuresis  nocturna,  729. 
illustrative  cases,  733. 
prognosis,  726. 
symptomatology,  724. 
treatment,  726. 
incontinence  of  urine,  729. 
prognosis,  729. 
treatment,  729. 

derangements  of  function  due  to  ab- 
normal condition  of  urine,  734. 
causation,  736. 
diagnosis,  736. 
illustrative  cases,  728. 
prognosis,  736. 
symptomatology,  736. 
treatment,  736. 

derangement  of  function  due  to  affec- 
tions of  the  pelvic  organs  other 
than  the  bladder,  740. 
Functional  diseases  of  urethra,  877. 
Functions  of  uterus,  181. 

gestation,  181. 

impregnation,  181. 

menstruation,  30. 

Galvano-eautery  of  Byrne,  417. 
Gartner's  duct,  patency  of,  873. 
Genital  cleft,  83. 

eminence,  83. 
Gestation,  ectopic,  650. 
Glands  of  Naboth,  180. 

vulvo-vaginal,  86. 
Glandulae  vestibulares  minores,  79. 

majores,  79. 
Gonorrhoea,  85. 
Goodell's  dilator,  17. 
Granular  erosion  of  urethra,  884. 

Hfematosalpinx,  591. 
etiology,  591. 
symptomatology,  591. 
treatment,  591. 


984 


DISEASES  OF  WOMEN. 


Hsemorrhage  of  the  bladder,  756. 
illustrative  cases,  760. 
treatment,  758. 
secondary,  140. 
Haeraorrhoid  clamp,  160. 
Haemostatic  forceps,  427. 
Hawk-bilL  scissors,  254. 
Hermaphroditism,  83. 
Hernia  of  the  bladder,  821. 
of  the  pudendum,  92. 
anterior  labial,  92. 
diagnosis,  93. 
posterior  labial,  92. 
treatment,  93. 
History  of  reproduction,  7. 
Hunter's  depressor,  14. 
Hydatids  in  the  bladder,  833. 
Hydrocele  of  round  ligament,  94. 

treatment,  94. 
Hydrosalpinx,  588. 
Hymen,  82. 

imperforate,  53. 
Hyperemia  of  the  bladder,  754, 
causation,  755. 
diagnosis,  755. 
symptomatology,  755. 
treatment,  756. 
Hypencsthesia  of  vagina,  110. 
of  vulva,  94. 
causation,  95. 
treatment,  95. 
Hyperplasia  of  bladder,  869. 
diagnosis,  8V0. 
treatment,  870. 
symptomatology,  870. 
Hypertrophy      of     the      cervix     uteri, 
350. 
causation,  353. 
pathology.  350. 
physical  signs,  352. 
prognosis,  353. 
symptomatology,  350. 
treatment,  353. 
Hypospadias,  83,  673. 
Hysterectomy,  a])dominal,  377. 
supra-vaginal,  375. 
vaginal,  422. 
clamp  operation,  424. 
author's  method,  427. 
French  method,  426. 
Keith's  cases,  394. 
Hysterotome,  Skene's,  75. 


Illustrative  cases  of   abuse  of  pessaries, 

344. 
Illustrative  cases — Bladder,  atrophy,  871. 

cystitis,  804. 

dislocations,  814. 

displacements,  823. 

functional  diseases,  712,  738. 
bladder,  foreign  bodies  in,  837. 

malformations  of,  686. 

paralysis  of.  733. 

prolapsus  of,  823. 

rupture  of.  851. 
cellulitis,  pelvic,  605. 
cervix  uteri,  cicatrices  of,  267. 

lacerations  of,  257. 
coccyx,  removal  of,  174. 
endometritis,  194. 

eorporejil,  214. 
fistula  in  ano,  167. 

urethral,  964. 

vesico-vaginal,  960. 
membranous  dysmenorrhoea,  242. 
menopause,  448. 

menstrual  derangements  caused  by  ar- 
rested growth  of  uterus,  41. 

chlorosis,  44. 

deranged  innervation,  49. 

deranged  conditions  of  life,  47. 

malformations  of  uterus.  32. 
ovarian  neoplasms,  506. 
pelvic  ha^matocele,  644. 
pelvic  peritonitis,  628. 
pudendal  ha^matoma,  92. 
ureter,  obstruction  of,  972-978. 
urethra :  dislocation,  923. 

functional  diseases  of,  878. 

organic  disease  of,  885. 

stricture  of,  931. 
urethral  glands,  gonorrhoeal  inflamma- 
tion of,  938. 

tuberculosis  of,  948. 
uterus,  anteflexion  of,  71. 

fibronux  of,  382. 

inversion  of,  271. 

retroflexion  of,  336. 

retroversion  of,  340. 
Imperforate  vagina,  102. 

hymen,  53. 
Incontinence  of  urine,  723,  729. 
Infantile  uterus,  23. 
Inflammation  of  bladder,  761. 
of  ovary,  485. 


INDEX. 


985 


.liinainiTiatiou   of  ovaiy,   aoute  ovaritis, 
488. 

causation,  493. 

diagnosis,  491. 

pathology,  489. 

physical  signs,  490. 

prognosis,  491. 

symptomatology,  490. 

treatment,  492. 
chronic  ovaritis,  493. 

causation,  496. 

pathology,  493. 

physical  signs,  495. 

I^rognosis,  495. 

symptomatology,  494. 

treatment,  496. 
hypera^mia,  485. 

causation,  488. 

pathology,  485. 

physical  signs,  487. 

prognosis.  488. 

symptomatology,  486. 

treatment,  488. 
of  urethra,  880. 
of  vagina,  106. 
acute,  106. 
chronic,  106. 
gonorrhoeal,  106. 
erysipelatous,  106. 
erythematous,  106. 
of  vulvo-vaginal  glands,  86. 
physical  signs,  86. 
prognosis,  87. 
symptomatology,  86. 
treatment,  87. 
Inflammatory  affections  of  uterus,  177. 
endometritis,  183. 
acute  corporeal,  183. 

causation.  184. 

prognosis,  184. 

treatment,  184. 
cervical,  184. 

causation,  189. 

cystic  degeneration,  186. 

pathology,  184. 

physical  signs,  189. 

prognosis,  190. 

symptomatology,  188. 

treatment,  190. 
constitutional,  191. 
local,  191. 
chronic,  184. 


Inguinal  labial  hernia,  92. 
Inhaler,  ether,  19. 
Injuries  of  pelvic  floor,  116. 
Instruments  u&ed  in  ovariotomy,  556. 
Intraligamentous  ovarian  cystoraata,  535. 
I)athology,  530. 
physical  signs,  537. 
symptomatology,  537. 
treatment,  539. 
Inversion  of  bladder,  838. 
Inversion  of  uterus,  271. 
causation,  275. 
chronic,  378. 
diagnosis,  274. 
physical  signs,  373. 
prognosis,  375. 
symptomatology,  271. 
treatment,  376. 

methods  of  reduction,  279. 
Barren.  379. 
Byrne,  381. 
Courty,  279. 
Noeggerath,  279. 
Thomas,  279. 

Knee-chest  position,  329. 

Labia  majora,  77. 

minora,  77. 
Lacerations,  cervix  uteri,  347, 
causation,  351. 
consequences,  347. 
frequency,  347. 
importance,  347. 
treatment,  354. 

operation,  354. 
varieties,  348. 

antero-posterior,  350. 
incomplete,  350. 
lateral,  348,  350. 
multiple,  350. 
levator-ani  muscle,  133. 
perineum,  152. 

through  sphincter-ani  muscle,  134. 
Laparo-salpingotomy,  591. 
Laparotomy:  after-treatment,  551. 
preparatory  treatment.  551. 
peritonitis  and  septicaemia  after,  566. 
Lesions  of  formation  of  ovary,  484. 
absent,  484. 
rudimentary,  484. 
supernumerary,  484. 


986 


DISEASES  OF   WOMEN. 


Levator-ani  muscle,  causes  of  injuries  to, 
127. 

Malformations  of  bladder,  677. 
anaspadias,  678. 
double  bladder,  678. 
diagnosis,  676. 
epispadias,  678. 
etiology,  679. 
eversio  vesica;,  678. 
exstrophia  per  urachum,  678. 
exstrophia  vesica^  677. 
extroversion,  676. 
fissure,  677. 

fistula- vesico-umbilicalis,  677. 
inversio  vesicae  cum  prolapsu  per  fis- 

suram,  678. 
prognosis,  676. 
treatment,  676. 
of  uterus,  25. 
absence,  27. 
at  puberty,  25. 
during  embryonic  life,  25. 
illustrative  cases,  28. 
uterus  bipartis,  25. 
uterus  bicornis,  26. 

bifundalis  unicollis,  26. 

duplex,  26. 

hypertrophy,  25. 

rudimentary,  27,  30. 

unicornis,  26. 
of  urethra,  672. 
atresia  urethras,  673. 
defectus  urethra?  externus,  672. 
defectus  urethra^  internus,  673. 
defectus  urethra;  totalis,  672. 
diagnosis,  675. 
double  urethra,  674. 
hypospadias,  673. 
symptomatology,  674. 
treatment,  676. 
of  vagina,  101. 
atresia,  102. 

acquired,  102. 

causation,  103. 

complete,  102. 

congenital,  102. 

illustrative  cases,  102. 

partial,  102. 

physical  signs,  103. 

symptomatology,  103. 

treatment,  104. 


Malformations  of   vagina,   Dupuytren's 
operation,  104. 

Pouteau's  trocar,  106. 
Sims's  dilator,  106. 
double  vagina,  101. 
impei'forate  hymen,  53. 
imperforate  vagina,  102. 
perpetuation  of  septum,  101. 
prognosis,  104. 
Malignant  disease  of  uterus,  403. 
cancer,  403. 

cancer  of  cervix  uteri,  403. 
cancer-juice,  404. 
colloid,  405. 
encephaloid,  405. 
epithelioma,  404. 
melanotic,  404. 
pathological  effects,  405. 
hydronephrosis,  405. 
rectitis,  405. 

vesico- vaginal  fistuLT.  405. 
pathology,  404. 
scirrhus,  405. 
definition,  404. 
sarcoma,  404. 
Meatus  urinarius,  79. 
Medullai-y  cancer,  410. 
Membranous  dysmenorrhcea,  234. 
causation,  238. 
illustrative  cases,  242. 
pathology.  234. 
physical  signs,  237. 
symptomatology,  236. 
treatment,  240. 

Barker's,  Fordyce,  case,  245. 
Menopause,  439. 
illustrative  cases,  448. 
premature,  442. 
symptomatology,  443. 
treatment,  444. 
Menstruation,  30. 
composition  of  menstrual  flow,  31. 
derangement  from  arrest  of  develop- 
ment, 30. 
illustrative  cases,  32. 
derangement  from  causes  independent 
of  sexual  organs,  46. 
illustrative  cases,  49. 
laws  of,  31. 

premature,  from  deranged  condition 
of  life  and  delayed  innervation, 
47. 


INDEX. 


987 


Methods  of  exploration  of  bladder  and 
urethra,  743. 

cystoscope,  740. 

Skene's  bivalve  urethral  speculum,  700. 

Skene's  endoscope,  744. 

urethroscope,  745. 
Metritis,  interstitial,  183. 

acute,  182. 

chronic,  183. 
Metro-elytrorrhaphy,  335. 
Microscope  in  diagnosis,  18. 
Minute  anatomy  of  ovary,  474. 
Mons  veneris,  77. 
Miiller's  ducts,  23. 

filaments,  33. 
Multilocular  cyst,  509. 
Myoma.  357. 

Naboth,  glands  of,  180. 
Needles,  Emmet's,  958. 
Keith's,  557. 
Peaslee's,  134. 
Skene's,  355. 
Needle  forceps,  147. 
Neoplasms  of  bladder,  858. 
benign,  858. 

fibi'oma,  858. 

myo-fibroma,  858. 

myoma,  858. 

myxoma,  858. 

tubercle,  866. 
malignant,  858. 

encephaloid,  858. 

epithelioma,  858. 

sarcoma,  858,  868. 

scirrhus,  858. 
of  Fallopian  tubes,  587. 

carcinoma,  587. 

cystoma,  587. 

fibroma,  587. 

lipoma,  587. 
,    Morgagni's  hydatid,  587. 

myoma.  587. 

papilloma,  587. 

sarcoma.  587. 

tubercle,  587. 
of  ovary,  506. 

adenoid  cystoma,  506. 

carcinoma,  506. 

cystic  tumors,  506. 

cysto-carcinoma,  506. 
fibroma,  506. 


Neoplasms  of  ovary,  cysto-sarcoma,  500. 

dermoid  cystoma,  506. 

follicular  cyst,  500. 

filjrous  cyst,  506. 

multilocular  cystoma.  506. 

multiple  cystoma,  500. 

multiple  follicular  cystoma,  506. 

papillary  cystoma,  SOU. 

sarcoma,  506. 

simple  follicular  cystoma.  500. 

simple  unilocular  cystoma.  506. 
of  urethra,  894. 

areolar,  896. 

compound,  897. 

epithelial,  897. 

glandular,  895. 

papillary,  895. 

vascular,  896. 
of  vagina,  110. 

carcinoma,  115. 

cysts,  110. 

fibroma,  114. 

fibromyoma,  114. 

myoma,  114. 

sarcoma,  115. 
Nymphae,  77. 

Observation,  methods  of,  1. 
Oophorectomy,  544. 
Orificium  vaginjB,  81. 
Ovarian  cysts,  507. 
classification,  506. 
complex  cystoma,  510. 
compound  cysts,  509. 
complications,  517. 

cystitis,  520. 

dragging  of  pedicle,  519. 

perforation,  520. 

rupture  of  cyst,  519. 
contents  of,  515. 
cyst-wall,  514. 
cysto-fibroma,  513. 
dermoid,  513. 
diagnosis,  535. 

ascites,  534. 

cyst  of  broad  ligament,  534. 

distended  bladder,  533. 

encysted  dropsy  of  peritonjeum,  533. 

enlargement    and    cysts    of    liver, 
spleen,  and  kidneys,  533. 

parovarian  cyst,  534. 

pregnancy,  531. 


988 


DISEASES  OF   WOMEN. 


Ovarian  cysts  :  uterine  fibroids  and  fibro- 
cysts,  535. 

fibroma  of  ovary,  513. 

intraligamentous,  535. 

microscopic  contents,  526. 

multilocular  cysts,  509. 

ovarian  granular  cell  (Drysdale),  517. 

papillary  cysts,  511. 

paroophoritic,  511. 

physical  signs,  523. 

simple  cysts,  508. 

symptomatology,  523. 
ovariotomy,  544. 
Ovarian  neoplasms,  506. 

hypersemia,  485. 
Ovaries,  anatomy  and  physiology  of,  469. 

displacements,  500. 

prolapsus,  501. 
Ovariotomy,  544. 

after-treatment,  565. 

assistants,  558. 

complications,  561. 

drainage,  564. 

emptying  cysts  in  complicated  cases, 
562. 

list  of  instruments  needed,  556. 

preparation  of  patient,  551. 

steps  of  operation,  559. 
Ovaritis,  acute,  485. 

chronic,  492. 
Ovulation,  477. 

Palma  plicata,  23. 

Palpation  and  percussion  conjoined,  21. 
Papillary  cysts.  511. 
Paquelin's  cautery,  115. 
Paralysis  of  bladder,  723. 
Parovarian  cysts.  534. 
Pelvic  cellulitis,  596. 
causation.  599. 
illustrative  cases,  605. 
pathology,  597. 
physical  signs,  603. 
symptomatology,  601. 
treatment,  603. 
Pelvic  colpo-hysteropaxy,  335. 
Pelvic  floor  :  anatomy,  116. 

bulbo-cavernosus  muscle,  117. 
coccygeus,  116. 
injuries,  116. 
lovator-ani  muscle,  116. 
transversus  perinaji  muscle,  116. 


Pelvic  floor  :  sagging  of,  127. 
sphincter-ani  muscle,  118. 
hajmatocele,  637. 
causation,  640. 
illustrative  eases,  643. 
intra-peritoneal,  638. 
pathology,  638. 
physical  signs,  641. 
subperitoneal,  638. 
symptomatology,  640. 
treatment,  642. 
peritonitis,  620. 
causation,  623. 
illustrative  cases,  628. 
pathology,  621. 
symptomatology,  624. 
treatment,  625. 
Percussion,  10. 
Perinasum,  116. 
anatomy,  116. 

bulbo-cavernosus  muscle,  117. 
levator-ani  muscle,  116. 
sphincter-ani  muscle,  118. 
transversus  perinjei  muscle,  116. 
functions,  120. 
injuries,  121. 
causation,  131. 
diagnosis,  124. 
illustrative  cases,  144. 
symptomatology,  129. 
treatment,  133. 
Perineorrluiphy,  133. 
conditions   necessary   for    healing    of 

wounds,  137. 
conditions  unfavorable  for  healing  of 

wounds,  133. 
description  of  operation  for  rupture  in 
median  line,  143. 
denudation,  145. 
instruments,  144. 
introduction  of  sutures,  148. 
description  of  operation  for  the  res- 
toration  of  sphincter-ani  muscle 
and  perinanim,  152. 
introduction  of  sutures,  155. 
vivifying,  154. 
primary  operation,  133. 
Peaslee's  needle,  134. 
silk  sutures,  135. 
silver  wire,  135. 
Peri-salfjingitis,  548. 
Pessaries,  abuse  of,  343. 


INDEX. 


989 


Pessaries,  adaptation  of,  323. 
Albert  Smith's,  333. 
glass  globe,  303. 
lever  action  of,  328. 
Peaslee's,  303. 

Skene's,  for  prolapsus  of  bladder,  819. 
stem,  69. 
Physiology  of  ovary,  438. 
Pregnancy  tubal,  651. 
Premature  menopause,  442. 
Preparation  of  silk  sutures,  146. 
Preputium,  78. 
Probe,  uterine,  14. 
Probing,  uterus,  16. 
Process  of  vivifying  tissues,  154. 
Prolapsus  of  ovary,  501; 
causation,  504. 
physical  signs,  503. 
prognosis,  503. 
symptomatology,  502. 
treatment,  504. 
uteri,  293. 
first  degree,  293. 
second  degi'ee,  293. 
third  degree,  293. 
treatment,  301. 
Pruritus  of  vulva,  95. 
pathology,  95. 
physical  signs,  95. 
symptomatology,  95. 
treatment,  96. 

by  galvano-cautery,  308. 
Pseudo-hermaphroditism,  84. 
Pudendal  haematoma,  92. 
Pudendum,  77. 
anatomy,  77. 
development,  82. 
diseases,  85. 
wounds  of,  88. 
Pyosalpins,  587. 

Rectum,  digital  touch  by,  10. 

examination  of  pelvic  organs  through, 
9. 
Recurrent  fibroids,  436. 
Reproduction,  history  of,  7. 
Retroflexion  of  the  uterus,  336. 

causation,  338. 

pathology,  336. 

physical  signs,  337. 

prognosis,  S39. 

symptomatology,  337. 


Retroflexion  of  the  uterus,  treatment,  340. 
Retroversion  of  uterus,  310. 

treated  by  pessaries,  318. 
Round  ligaments,  329. 
Rudimentary  uterus,  34. 
Rupture  of  bladder,  847. 

causation,  850. 

complete,  847. 

incomplete,  847. 

pathology,  847. 

prognosis,  849. 

symptomatology,  848. 

treatment,  850. 

Sagging  of  the  pelvic  floor,  131. 
Salpingitis,  587. 
acute,  587. 
causation,  589. 
chronic,  588. 
illustrative  eases,  593. 
pathology,  587. 
jjhysical  signs,  589. 
prognosis,  589. 
symptomatology,  588. 
treatment,  589. 
Sarcoma  of  uterus,  436. 
causation,  438. 
diagnosis,  438. 
pathology,  436. 
physical  signs,  437. 
prognosis.  438. 
symptomatology,  437. 
treatment,  438. 
Scirrhus,  404. 
Scissors  for  removing  sutures,  151. 

hawk-bill,  254. 
Sclerosis  of  uterus,  224. 
causation,  227. 
illustrative  cases,  228. 
pathology,  224. 
prognosis,  227. 
physical  signs,  227. 
symptomatology,  226. 
treatment,  228. 
of  cervix  uteri,  228. 

following  puerperal  meti'itis,  229. 
resulting  from  endometritis  and  gen- 
ei*al  congestion,  231. 
Senile  endometritis,  458. 
Sexual  organs,  development  of,  22. 
Silk  sutures,  preparation  of,  146. 
Silver  wire,  135. 


990 


DISEASES   OF   WOMEN. 


Simple  cyst,  508. 

Sims's  vaginal  dilator,  106. 

sponge-holder,  957. 
Skene's  glands,  G64. 

hemostatic  forcejjs,  427. 

hysterotome,  75. 

needles,  255. 

scissors,  254. 
Sounds,  uterine,  14. 

Jenks's,  14. 

Sims's,  14. 
Speculum :  Cusco's,  11. 

method,  752-903. 

movements  of,  13. 

Sims's,  11. 
Sponge-holders :  Sims's,  957. 
Stricture:    at   junction   of   urethra  and 
bladder,  929. 

of  urethra,  927. 
Subinvolution  of  uterus  after  parturition, 
219. 

causation,  219. 

pathology,  219. 

physical  signs,  220. 

prognosis,  220. 

symptomatology,  220. 

treatment,  221. 
Superinvolution  of  uterus,  222. 
Sutures,  141. 
Syphilis,  85. 
Systems,  5. 

muscular,  5. 

nervous,  5. 

nutritive,  5. 

sexual,  5. 

Tenaculum,  Sims's,  956. 
Tents,  17. 

Touch,  examination  by,  8. 
Tubal  pregnancy,  651. 
Tubes,  Fallopian,  22. 
Tubo-ovariotomy,  554. 

Ureters,  diseases  and  injuries  of,  968. 

catheterization  of,  750,  969. 
Urethra,  anatomy  of,  663. 

development,  670. 

digital  dilatation,  9. 

diseases  of,  878. 

fistula,  927,  963. 

malformation  of,  672. 

neoplasms,  894. 


Urethritis,  880. 
Urethroscope,  745. 
Uro-genital  sinus,  83. 
Use  of  catheter,  143. 
Uterus,  23. 

absence  of,  25. 

anatomy  of,  177. 

at  puberty,  24. 

bicornis,  25. 

bifundalis  unicollis,  25. 

bipartis,  25. 

bleeding  disease  of,  363. 

development  of,  22. 

dislocations  of,  284. 

displacements  of,  292. 
anteversion,  292. 
prolapsus,  293. 
retroversion,  310. 

double,  28. 

duplex,  26. 

functions  of,  181. 

hypertrophy  of,  25. 

infantile,  23. 

inflammatory  affections  of,  183. 

malformations  of,  25. 

mature,  24. 

retroversion  of,  310. 

rudimentary,  25. 

unicornTs,  25. 
Uterine  dilator,  17. 

fibro-cysts.  360. 

fibroids.  356. 

probe,  14. 

sound,  14. 

Vagina :  anatomy  of,  100. 

atresia  of,  102. 

cysts  of,  110. 

development  of,  22. 

double,  28. 

imperforate,  102. 

malformations  of.  101. 

neoplasms  of,  110. 
Vaginal  dilator,  Sims's,  106. 

enterocele,  93. 
causation,  93. 
diagnosis,  93. 
treatment,  94. 
Vaginismus,  110. 
Vaginitis,  106. 

acute,  106. 

catarrhal,  107. 


INDEX. 


991 


Vaginitis,  causation,  108. 

chronic,  lOG. 

diphtheritic,  lUG. 

erysipelatous,  lOG. 

erythematous,  106. 

exudative,  107. 

gonorrhoeal,  106, 

idiopathic,  106. 

patliology,  106. 

physical  signs,  108. 

prognosis,  108. 

purulent,  107. 

secondary,  106. 

subacute,  107. 

symptomatology,  107. 

treatment,  108. 
Varicose  veins  of  vulva,  88. 

causation,  88. 

physical  signs,  88. 

symptomatology,  88. 

treatment,  88. 
Ventral  fixation,  333. 
Vesical  and  urethral  fistuliB,  951. 

causacion,  953. 

classification,  951. 
urethro- vaginal,  951. 
utero-vaginal,  951. 
vesico- vaginal,  951. 

complications,  953. 

illustrative  cases,  960. 

physical  signs,  952. 

preparatory  treatment,  954. 

prognosis,  953. 

symptomatology,  953. 

treatment,  954. 


Vesical  fistula?,  after-treatment,  960. 
operation,  955. 
Emmet's  needles,  958. 
introduction  of  sutures,  957. 
paring  the  edges  of  fistula,  956. 
Sims's  sponge-holder,  957. 
Sims's  tenaculum,  956. 
Vesico-rectal  examination,  21. 
Vesico-urethral  fissure,  888. 
Vesico-uterine  fistula,  960,  905. 
Vesico-vaginal  examination,  10. 

fistula,  950. 
Vestibule,  78. 
Vulvitis,  85. 
causation,  85. 
diagnosis,  86. 

due  to  cancer  of  uterus,  85. 
due  to  vaginitis,  85. 
erythematous,  85. 
follicular,  85. 
gonorrhoeal,  85. 
physical  signs,  85. 
primary,  85. 
purulent,  85. 
secondary,  85. 
symptomatology,  85. 
syphilitic,  85. 
treatment,  86. 

Wounds  of  pudendum,  88. 
contused,  90. 
incised  and  punctured,  89. 

causation,  89. 

symptomatology,  89. 

treatment,  89. 


THE    END. 


y%i   ' 

'\ 

DATE  DUE                                i 

MAI 

16 1995 

JUN6    IS 

95. 

-t. . 

"-*• 

-r" 

' 

' 

PrInIM 
inUSA 

COLUMBIA  UNIVERSITY  LIBRARIES 


0037566776 


■^^:  >i;\L^  -yt 


RGlOl 
1900 
Skene 

Treatise  on  diseases  of  women. 


U'U^.ns 


.  ..^A    »:■  .1M.  Py^.H  MiM 


